Essential public health operations in Slovenia: key findings and recommendations on strengthening public health capacities and services

Essential public health operations in Slovenia Key findings and recommendations on strengthening public health capacities and services Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro. who.int/pubrequest). Abstract Keywords PUBLIC HEALTH SYSTEM PUBLIC HEALTH SERVICES PUBLIC HEALTH ORGANIZATION PUBLIC HEALTH RESEARCH PUBLIC HEALTH FINANCING PUBLIC HEALTH COMMUNICATION ESSENTIAL PUBLIC HEALTH OPERATIONS Between 2017 and 2019, the Ministry of Health of the Republic of Slovenia, in collaboration with the WHO Regional Office for Europe, initiated a self-assessment of the essential public health operations in Slovenia. The aim of the assessment was to support the strengthening and modernization of the public health capacities and services in the country, in line with the European Action Plan for Strengthening Public Health Capacities and Services (2012–2020). The process, which involved the participation of over 130 professionals, resulted in 49 recommendations, which will serve as a basis for the preparation of a strategy for the development of public health services in Slovenia. © World Health Organization 2021  Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by- nc-sa/ 3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Designed by: Christophe LANOUX Cover photo: © Aleš Fevžer ISBN: 978-92-890-5589-5 Essential public health operations in Slovenia Key findings and recommendations on strengthening public health capacities and services ii Foreword by Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe Foreword by Minister of Health of the Republic of Slovenia Foreword by the Director of the National Institute of Public Health of Slovenia Acknowledgements Abbreviations Executive summary: directions for the future of public health in Slovenia Priority areas for building an effective public health system Introduction Methodology Key findings of the EPHO assessment in Slovenia EPHO 1. Surveillance of population health and well-being Health-data sources and tools Surveillance of population health Surveillance of health-system performance Data integration, analysis and reporting EPHO 2. Monitoring and response to health hazards and emergencies Identification and monitoring of health hazards Preparedness for and response to public health emergencies Implementation of IHR EPHO 3. Health protection, including environmental and occupational health and food safety, among others Environmental health protection Occupational health protection Food safety Patient safety Road safety Consumer-product safety EPHO 4. Health promotion, including action to address social determinants and health inequity Intersectoral and interdisciplinary capacity Addressing the behavioural, social and environmental determinants of health through a whole-of-government, whole-of-society approach EPHO 5. Disease prevention, including early detection of illness Primary prevention Secondary prevention Tertiary/quaternary prevention Social support iv v vi vii xiv xv xvi 1 2 7 7 7 8 8 9 10 10 11 11 12 12 12 13 13 13 14 15 15 16 19 19 20 21 21 Contents EPHO 6. Assuring governance for public health Leadership for a whole-of-government, whole-of-society approach to health and well-being Health-policy cycle Regulation and control EPHO 7. Assuring a sufficient and competent public health workforce Human-resources-development cycle Human-resources management Public health education Governance of human resources for public health EPHO 8. Assuring sustainable organizational structures and financing Organizational structures and mechanisms Financing public health services EPHO 9. Advocacy, communication and social mobilization for health Strategic and systematic approach to public health communication ICT for health EPHO 10. Advancing public health research to inform policy and practice Setting a national research agenda Capacity-building Coordination of research activities Dissemination and knowledge brokering Policy recommendations EPHO 1 EPHO 2 EPHO 3 EPHO 4 EPHO 5 EPHO 6 EPHO 7 EPHO 8 EPHO 9 EPHO 10 Conclusions References Subject index 22 22 22 23 24 24 26 26 27 28 28 29 30 30 31 32 32 32 33 33 35 35 37 39 42 46 49 51 54 57 59 63 64 66 iii iv Foreword by Director of the Division of Country Health Policies and Systems, WHO Regional Office for Europe I am delighted with this joint publication on the Slovenian self-assessment of essential public health operations (EPHOs). Slovenia has indeed a long and established tradition in public health and has shown commitment towards strengthening EPHOs with the aim of improving the health of the population. The COVID-19 pandemic has illustrated that there is a need for strong public health capacities and services in all countries and that periodic thorough assessments of such capacities allow for the identification of areas in need of further development. For over 10 years, the WHO Regional Office for Europe has actively supported the Member States in conducting self- assessments of EPHOs by providing guidance on the process and the opportunity for core self-assessment groups to reflect where needed. We had the pleasure of doing so again during the process in Slovenia. This publication marks an important milestone in the self-assessment of EPHOs, allowing not only Slovenia but also other Member States to benefit from the findings of the Slovenian self- assessment. Cross-country learning and the sharing of experience form an essential part of improving public health in the European Region as a whole. The challenge ahead is clear. I look forward to seeing the fruits of this work emerge over the coming years. Natasha Azzopardi Muscat Director, Division of Country Health Policies and Systems WHO Regional Office for Europe © WHO vForeword by Minister of Health of the Republic of Slovenia Slovenia has a long tradition in public health, essentially contributing to excellent health results in the country for almost a century. The science and practice of public health have been systematically developed and carefully nurtured, and its contribution to the design and implementation of health and health-affecting policies has been highly valued. The COVID-19 pandemic, relentlessly and without selection, revealed strengths, weaknesses and missed opportunities in many areas of society, including that of health. On the other hand, in times of increased investment in health, opportunities to realize many long-awaited improvements are emerging. Health is, as never before, a matter for a whole-of-government approach and thus is high on the political agenda. In Slovenia, the development of public health in line with the most recent scientific advances in the field was a health-policy priority already before the COVID-19 epidemic. To assess the needs and provide scientific evidence for the progressive strengthening of public health capacities systematically, we carried out an assessment of the 10 essential public health operations (EPHOs) in Slovenia, in accordance with methodology of the WHO Regional Office for Europe. This was a participatory process, engaging more than 130 professionals from all key stakeholders in public health, including scientific institutions, various ministries, and nongovernmental organizations (NGOs). It was conducted with strong technical guidance from the WHO Regional Office for Europe and the support of the WHO Slovenia Country Office and resulted in 49 actionable recommendations to strengthen public health capacities and services. Although the self-assessment was conducted before the COVID-19 pandemic, its recommendations adequately address the most urgent challenges emerging from the crisis. The lessons learned (per p. 7 in the 2019 Style Notes), however, contribute to an even deeper understanding of the specific needs for further development in public health. The special added value of the EPHO evaluation process is in connecting partners from different public health and other institutions and creating opportunities for systematic deliberation on public health needs. The process also contributed to a common understanding of public health operations and allowed for reflection on measures that could opportunely be implemented in Slovenia in accordance with the strategic guidelines of the WHO European Programme of Work 2020–2025. The self-assessment was carried out in the framework of the implementation of the Resolution on the National Health Care Plan 2016–2025. Its findings and recommendations will serve as a starting point in the preparation of a strategy for the development of public health services in Slovenia. Slovenia is looking forward to the future with the health and well-being of the people at the centre of a balanced economic, social, and environmental development, which takes the limitations of the planet into account and creates conditions and opportunities for present and future generations. The public health services will continue to contribute to achieving these goals. During its Presidency to the Council of the European Union in 2021, Slovenia will promote international collaboration in developing innovative solutions to the health challenges of today and tomorrow. I am convinced that, based on the results of the EPHO self-assessment in Slovenia, many innovative solutions in public health will also be developed and implemented. Janez Poklukar Minister of Health of the Republic of Slovenia © MZ vi Foreword by the Director of the National Institute of Public Health of Slovenia Public health capacities and services in Slovenia are continuously being developed to allow the identification and prediction of social and environmental factors of concern and enable appropriate response to the changing health needs of the population. The COVID-19 pandemic has underlined the need for systematically and carefully developed public health services, which can respond and adapt quickly. As the central public health institution in Slovenia, the National Institute of Public Health (NIJZ) takes full charge of the development of the public health profession and the science in this area. The essential public health operations (EPHO) self-assessment in Slovenia has contributed to this development, many NIJZ professionals having been engaged in the process. The value of the self-assessment lies not only in the final result, namely, the key findings and recommendations on strengthening public health capacities and services, but also – and even more so – in its systematic participatory process, carefully conducted using the designated methodology of the WHO European Region, which served to build valuable connections, partnerships and friendships among a broad network of stakeholders. The process itself offered public health professionals from all over the country the opportunity to meet and discuss in detail the meaning of essential public health operations, the roles of the different actors involved, and the current strengths and future needs of the country in this area. It illustrated yet again that collaboration is the key to success in public health. I wish to thank those colleagues and partners in public health in Slovenia who participated in the process for their contributions to this publication. During several months of deliberations, they were able to look beyond their usual areas of work, step out of their comfort zones, demonstrate the will to compromise, and truly model the kind of collaboration that is urgently needed to move our public health services forward. My sincere thanks also go to the WHO Regional Office for Europe team for its excellent, innovative approach to leading the participatory process, which resulted in building national capacities in public health. The recommendations reached on strengthening public health services and capacities will serve as a basis for the elaboration of both a national public health strategy and a strategic plan for NIJZ. I am looking forward to this next step, which will accelerate the development of innovative, forward-looking public health services and capacities that are fit to tackle future challenges. Milan Krek Director, National Institute of Public Health of Slovenia © NIJZ Acknowledgements “Essential public health operations in Slovenia: key findings and recommendations on strengthening public health capacities and services” was co-produced by the Ministry of Health of the Republic of Slovenia, the National Institute of Public Health of Slovenia (NIJZ), and the WHO Regional Office for Europe. The publication is the result of the collaborative effort of the following experts who are listed according to their participation in the essential public health operations (EPHO) self-assessment process in Slovenia (2017–2019). vii EPHO self-assessment process: coordination, management, leadership, facilitation, administration Pia Vračko Eva Murko Vesna-Kerstin Petrič Mojca Gobec Maria Marcoulli Martin Krayer von Krauss Anna Cichowska Myrup Meggan Harris Darina Sedláková Aiga Rurane James Ede Marjeta Novak Natalija Vrhunc Liza Zorman Anita Štefin Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Resident Physician, National Institute of Public Health, Ljubljana, Slovenia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Director, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Consultant, WHO Regional Office for Europe, Copenhagen, Denmark Senior Advisor, WHO Regional Office for Europe, Copenhagen, Denmark Programme Manager, WHO Regional Office for Europe, Copenhagen, Denmark Consultant, WHO Regional Office for Europe, Copenhagen, Denmark Head (to end 2018), WHO Slovenia Country Office, Ljubljana, Slovenia Head (from 2019), WHO Slovenia Country Office, Ljubljana, Slovenia Senior Partner, Status Flow ApS, and Consultant, WHO Regional Office for Europe Deep Dialogue Host and Collaborative Change Catalyst, Humus.si, Ljubljana, Slovenia, and Consultant, WHO Regional Office for Europe Facilitator and Coach, Natalija Vrhunc, s.p., Rakek, Slovenia, and Consultant, WHO Regional Office for Europe Undersecretary, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Administrative Assistant, WHO Slovenia Country Office, Ljubljana, Slovenia EPHO 1. Surveillance of population health and well-being EPHO 2. Monitoring and response to health hazards and emergencies EPHO 3. Health protection, including environmental and occupational health and food safety, among others Metka Zaletel Tina Lesnik Vesna Zadnik Ada Hočevar Grom Tina Zupanič Darja Lavtar Mircha Poldrugovac Nuška Čakš Jager Katja Šuštaršič Marjeta Recek Vesna Viher Hrženjak Ana Hojs Simona Perčič Simona Uršič Majda Pohar Karmen Krajnc Janja Turšič Darko Mehikić Alojz Zupanc Blaž Pipan Head, Health Data Department, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, National Institute of Public Health, Ljubljana, Slovenia Head, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Statistician Methodologist, National Institute of Public Health, Ljubljana, Slovenia Statistician Methodologist, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Trainee, National Institute of Public Health, Ljubljana, Slovenia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Head, Centre for Environment and Health, National Laboratory for Health, Environment and Food, Maribor, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, Regional Unit Celje, National Institute of Public Health, Celje, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Secretary, Chemical Office of the Republic of Slovenia, Ljubljana, Slovenia Director, Office of the State of the Environment, Slovenian Environment Agency, Ljubljana, Slovenia Health Inspectorate of Republic of Slovenia, Ljubljana, Slovenia Secretary, Chemical Office of the Republic of Slovenia, Ljubljana, Slovenia Analyst, Chemical Office of the Republic of Slovenia, Ljubljana, Slovenia viii ix EPHO 4. Health promotion, including action to address social determinants and health inequity Sonja Tomšič Matej Vinko Eva Murko Tatjana Krajnc Nikolić Helena Koprivnikar Mojca Gabrijelčič Blenkuš Barbara Mihevc Ponikvar Head, Analysis and Development of Health Department, National Institute of Public Health, Ljubljana, Slovenia Resident Physician, National Institute of Public Health, Ljubljana, Slovenia Resident Physician, National Institute of Public Health, Ljubljana, Slovenia Head, Regional Unit Murska Sobota, National Institute of Public Health, Murska Sobota, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Martina Juder Kogler Vesna Zupančič Maja Kokalj Mateja Rok Simon Maja Roškar Mercedes Lovrečič Barbara Lovrečič Lucija Perharič Sonja Jeram Pavel Pollak Stanka Kirinčič Irena Veninšek Perpar Ivanka Gale Anja Jutraž Peter Otorepec Resident Phsyician, National Laboratory for Health, Environment and Food, Maribor, Slovenia Undersecretary, Sector for Quality and Organization of Health Care, Directorate for Health Care, Ministry of Health, Ljubljana, Slovenia Secretary, Food, Feed and Medicinal Products Division, Ministry of Agriculture, Forestry and Food, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Research and Development Associate, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia National Public Health Expert, National Institute of Public Health, Ljubljana, Slovenia Health Analyst Researcher, National Institute of Public Health, Ljubljana, Slovenia National Public Health Expert, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Research and Development Associate, National Institute of Public Health, Ljubljana, Slovenia Head, Environmental Health Department, National Institute of Public Health, Ljubljana, Slovenia xMilan Krek Nuša Konec Juričič Mateja Rok Simon Mercedes Lovrečič Barbara Lovrečič Head, Regional Unit Koper, National Institute of Public Health, Koper, Slovenia Specialist Physician, Senior Advisor, Regional Unit Celje, National Institute of Public Health, Celje, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia EPHO 5. Disease prevention, including early detection of illness Alenka Hafner Nives Letnar Žbogar Pia Vračko Urška Ivanuš Barbara Mihevc Ponikvar Veronika Učakar Alenka Trop Skaza Marta Grgič Vitek Matjaž Krošel Dominika Novak Mlakar Sanja Vrbovšek Olivera Stanojevič Jerković Polonca Truden Dobrin Evita Leskovšek Katja Jarm Mateja Krajc Head, Regional Unit Kranj, National Institute of Public Health, Kranj, Slovenia Head, Regional Unit Ljubljana, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head of Department and National Programme ZORA, Institute of Oncology Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head, Regional Unit Celje, National Institute of Public Health, Celje, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Resident Physician, National Institute of Public Health, Ljubljana, Slovenia Head, Colorectal Cancer Screening Programme, National Institute of Public Health, Ljubljana, Slovenia Expert Associate, National Institute of Public Health, Ljubljana, Slovenia Head, Regional Unit Maribor, National Institute of Public Health, Maribor, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head, Register and Call Center of the DORA programme, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Slovenia Head, Oncology Genetic Counselling and Testing Clinic, Institute of Oncology Ljubljana, Slovenia xi EPHO 6. Assuring governance for health Vesna-Kerstin Petrič Pia Vračko Ivan Eržen Jožica Maučec Zakotnik Tatjana Buzeti Sladjana Jelisavčić Maja Rupnik Potokar Zora Levačič Tina Jamšek Marjan Premik Marija Magajne Marjeta Recek Milan Krek Mojca Gabrijelčič Blenkuš Tit Albreht Mojca Gobec Silva Nemeš Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Director, National Institute of Public Health, Ljubljana, Slovenia State Secretary, Ministry of Health, Ljubljana, Slovenia Director, Directorate for Long-term Care, Ministry of Health, Ljubljana, Slovenia Head of Field for Health Care Analytics and Economics, Health Insurance Institute of Slovenia, Ljubljana, Slovenia Secretary, Directorate for Health Care, Ministry of Health, Ljubljana, Slovenia Director, National Laboratory for Health, Environment and Food, Maribor, Slovenia Secretary, Head of Sector for Coordination of Health Care, Directorate for Health Care, Ministry of Health, Ljubljana, Slovenia Professor Emeritus, Medical Faculty, University of Ljubljana, Slovenia Director, Community Health Center Idrija, Slovenia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Directorate for Public Health, Ministry of Health, Ljubljana, Slovenia Head, Regional Unit Koper, National Institute of Public Health, Koper, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head, Health Systems Department, National Institute of Public Health, Ljubljana, Slovenia Director, Directorate for Public Health, Ministry of Health, Ljubljana, Slovenia Project Manager, Center for Health and Development Murska Sobota, Slovenia EPHO 7. Assuring a competent public health workforce Vesna Bjegović Mikanović Vesna-Kerstin Petrič Rade Pribaković Brinovec Eva Murko Vice Dean, Medical Faculty, University of Belgrade, Serbia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Head, Prevention and Promotion Programme Management Department, National Institute of Public Health, Ljubljana, Slovenia Resident Physician, National Institute of Public Health, Ljubljana, Slovenia EPHO 8. Assuring organizational structures and financing EPHO 9. Advocacy, communication and social mobilization for health Peggy Honoré Tit Albreht Mircha Poldrugovac Radivoje Pribaković Brinovec Vesna Viher Hrženjak Boris Kramberger Dunja Sever Darko Mehikić Urška Ivanuš Vesna-Kerstin Petrič Marjeta Recek Tjaša Čretnik-Žohar Ana Šinkovec Maja Kostanjšek Saška Terseglav Full Professor, Louisiana State University, Baton Rouge, USA Head, Health Systems Department, National Institute of Public Health, Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head, Prevention and Promotion Programme Management Department, National Institute of Public Health, Ljubljana, Slovenia Head, Centre for Environment and Health, National Laboratory for Health, Environment and Food, Maribor, Slovenia Senior Advisor, Health Insurance Institute of Slovenia, Ljubljana, Slovenia Chief Health Inspector, Health Inspectorate of the Republic of Slovenia, Ljubljana, Slovenia Health Inspectorate of the Republic of Slovenia, Ljubljana, Slovenia Head of Department and National Programme ZORA, Institute of Oncology Ljubljana, Slovenia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Directorate for Public Health, Ministry of Health, Ljubljana, Slovenia Head, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Head, Centre for Medical Microbiology, National Laboratory for Health, Environment and Food, Maribor, Slovenia Public Relations Officer, Ministry of Health, Ljubljana, Slovenia Public Relations Officer, Ministry of Health, Ljubljana, Slovenia Public Relations Officer, Association of Health Institutions of Slovenia, Ljubljana, Slovenia Pia Vračko Milan Krek Tatjana Krajnc Nikolić Ivan Eržen Liljana Zaletel Kragelj Brigita Skela Savič Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia Head, Regional Unit Koper, National Institute of Public Health, Koper, Slovenia Head, Regional Unit Murska Sobota, National Institute of Public Health, Murska Sobota, Slovenia Director, National Institute of Public Health, Ljubljana, Slovenia Head of Public Health Department, Medical Faculty, University of Ljubljana, Slovenia Dean, Angela Boškin Faculty of Health Care, Jesenice, Slovenia xii EPHO 10. Advancing public health research to inform policy and practice Agata Zupančič Eva Batista Daška Roškar Vesna Zadnik Mircha Poldrugovac Sandra Radoš Vesna Viher Hrženjak Zaletel Kragelj Ivan Eržen Undersecretary, Division for Health Promotion and Prevention of Noncommunicable Diseases, Public Health Directorate, Ministry of Health, Ljubljana, Slovenia Secretary, Ministry for Education, Science and Sport, Ljubljana, Slovenia National Public Health Expert, National Institute of Public Health, Ljubljana, Slovenia Head, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Slovenia Specialist Physician, Senior Advisor, National Institute of Public Health, Ljubljana, Slovenia National Public Health Expert, National Institute of Public Health, Ljubljana, Slovenia Head, Centre for Environment and Health, National Laboratory for Health, Environment and Food, Maribor, Slovenia Medical Faculty, University of Ljubljana, Slovenia Director, National Institute of Public Health, Ljubljana, Slovenia Nuša Kerč Amela Duratović Konjević Andreja Mojškrc Jan Peloza Ksenija Lekič Dalibor Stanimirović Public Relations Officer, National Institute of Public Health, Ljubljana, Slovenia Public Relations Officer, Institute of Oncology Ljubljana, Slovenia Public Relations Officer, Health Inspectorate of the Republic of Slovenia, Ljubljana, Slovenia Director, No Excuse, Ljubljana, Slovenia Development Associate, National Institute of Public Health, Ljubljana, Slovenia Head, Health Care Informatics Department, National Institute of Public Health, Ljubljana, Slovenia Of these experts: Pia Vračko, Eva Murko and Vesna-Kerstin Petrič drafted and edited many sections of the publication and coordinated the process; Meggan Harris was instrumental in synthesizing the contributions of many colleagues and in articulating key messages; Martin Krayer von Krauss, Anna Cichowska Myrup and Maria Marcoulli provided guidance on the process and supported the effort throughout; Metka Zaletel, Nuška Čakš Jager, Vesna Viher Hrženjak, Alenka Hafner, Sonja Tomšič, Vesna-Kerstin Petrič, Rade Pribaković Brinovec, Tit Albreht, Ana Šinkovec and Agata Zupančič led the EPHO Specialized Teams, facilitating data collection, consensus building and the formulation and prioritization of the recommendations, and drafted the respective chapters of the publication; James Ede, Marjeta Novak and Natalija Vrhunc provided expertise in participatory leadership and process-facilitation services; and Vesna-Kerstin Petrič, Mojca Gobec, Darina Sedláková and Aiga Rurane took leadership of the technical consultations. The input of many colleagues working in various institutions, organizations, ministries, and governmental and nongovernmental organizations in Slovenia, who shared their expertise in and knowledge of the field, is also very much appreciated. xiii xiv Abbreviations EAP-PHS European Action Plan for Strengthening Public Health Capacities and Services EPHO(s) essential public health operation(s) EU European Union EWRS Early Warning and Response System HIA health impact assessment HiAP Health in All Policies HTA health technology assessment ICT information and communication technology IHR International Health Regulations MDDSZEM Ministry of Labour, Family, Social Affairs and Equal Opportunities NCDs noncommunicable diseases NGOs nongovernmental organizations NIJZ National Institute of Public Health Slovenia NLZOH National Laboratory for Health, Environment and Food PREMs patient-reported experience measures PROMs patient-reported outcome measures RNMHP Resolution on the National Mental Health Programme 2018–2028 SOPs standard operating procedures URSZR Administration of the Republic of Slovenia for Civil Protection and Disaster Relief ZZZS Health Insurance Institute of Slovenia xv Executive summary: directions for the future of public health in Slovenia Between 2017 and 2019, the Ministry of Health of Slovenia, in collaboration with the WHO Regional Office for Europe and the WHO Country Office of Slovenia, launched a comprehensive self-assessment of the 10 essential public health operations (EPHOs) in the country. In the time it has taken to reach completion, the project has engaged scores of professionals in every corner of the health system, generating a detailed description of both the system’s strengths and the areas requiring further development. The COVID-19 pandemic has illustrated that the need to strengthen public health services in Slovenia is currently as great as it has ever been. This report lays out the key findings and recommendations of this participatory process. In general, public health is well integrated in the health system, with important strengths contributing to its effectiveness (Table 1). EPHO Major strengths 1. The health-information system systematically collects a wide range of health data and reports on indicators; much of these data can be cross-checked and linked to other health and non-health information systems. The Cancer Registry of the Republic of Slovenia stands out as a world-class system. 2. The country operates systems for the prediction of, preparedness for, and response to emergencies. Its system of risk assessment and preparedness for outbreaks of communicable diseases is among the strongest. 3. With some exceptions, legislative and enforcement mechanisms to protect public health and the environment are rigorous. The most complete regulatory coverage is in the areas of outdoor air and water, food safety, road safety, and consumer-product safety. 4. In terms of health promotion, which includes intersectoral activities to address core health determinants, Slovenia has picked up the pace of its activities, pursuing intersectoral projects and partnerships in numerous areas, most notably in those of education, physical activity and nutrition, tobacco control and road safety. 5. Disease-prevention services are widely available, and work to extend access to the most vulnerable people in Slovenia is ongoing. Links between public health, primary care, local communities, and civil society are growing and deepening. 6. The Slovenian Constitution guarantees citizens the right to health and health care, establishing a solid mandate for public health governance. Today, the National Health Care Plan 2016–2025 lays down Slovenia’s high-level political commitment to continue improving population health. 7. The public health workforce, though low in number, is a highly professional body with good regional programmes that could act as a springboard for building additional capacity needed. 8. Several strong institutions are responsible for organizing and financing the public health system. Recent years have seen major reorganizations of existing structures, including the National Institute for Public Health (NIJZ), and a growing budget for public health activities. 9. Health communication enjoys wide recognition as the linchpin for connecting services to the population, and an e-health system has been rolled out. 10. Although public health is not nationally recognized as a research discipline in its own right, Slovenian investigators are active leaders in and contributors to international public health projects; thus, the country’s research community is well placed on the European and international stages. Table 1. Ten EPHOs of the health system in Slovenia: major strengths xvi Consensus priority recommendations for building public health capacities also emerged from the self-assessment. These reflect the collective contributions of all participants in the process. The recommendations can be broadly divided into two groups: the first relates to cross-cutting measures that build public health capacities from within, while the second directly addresses activities to strengthen individual programmes. An explanation of these is provided below, followed by the full list of recommendations. HuMAN rESOurCES Chronic staff shortages and lack of organized, multidisciplinary training opportunities for non-medical professionals limit Slovenia’s capacity to provide modern, integrated public health services. In line with the priorities laid out in the National Health Care Plan 2016–2025, there is an urgent need to develop a strategic human-resources plan (see recommendation R7.1). The centrepiece of such a plan could be the establishment of a national school of public health (R7.2), which – in addition to organizing modern training courses – could serve as the focal point for intersectoral public health networks. Public health education should be available to all professionals who deliver public health services – not just medical professionals (R7.3). Moreover, in areas like emergency preparedness, training must be based on multisectoral collaboration so that the workforce is equipped to respond quickly and jointly to public health threats (R2.3). Other stakeholders, including the media, policy-makers and community leaders, could also benefit from practical learning opportunities that empower them to better understand technical evidence (R7.4). HEAlTH- INfOrMATION SySTEMS Gaps in data availability, accessibility, and connectivity constituted a recurring concern among assessment teams. This problem is seen as undercutting a wide range of capacities, health-care services, intersectoral linkages and traditional public health operations, for example, in the area of environmental health. The Healthcare Databases Act is commonly seen as outdated, prompting the need for a renewed political and legal consensus on the databases and registries that are required, and on how to link these effectively through state-of-the-art information technology (R1.1). The health-care information system alone is complex enough to merit targeted action (R1.2); the collection of outpatient and patient- centred data (R1.3) and the full implementation of the e-health system (R9.3) stand out as priorities. INSTITuTIONAl ExPANSION AND rEOrGANIzATION Priority areas for building an effective public health system The two main institutional stewards of public health in Slovenia, the Ministry of Health and NIJZ, are stretched beyond capacity; moreover, their responsibilities are not explicitly distributed or linked by a common strategic vision. The development of a national strategy for the development of the public health system (R6.1), a core programme envisaged in the National Health Care Plan 2016–2025, should set the course for advancing public health capacities and services. However, expanding the scope of public health activities – and the institutional governance challenges inherent to that process – will require new structures and institutions. Beyond the funding shortfalls that affect specific areas, like public health laboratories (R8.6), the principal problem with the financing and planning aspects of public health services is the short-term, project-based outlook. Many public health services are highly dependent on acting according to earmarked funding, allocated in reaction to political mandates or according to international priorities, rather than proactively addressing long- term public health challenges. Thus, while it is still desirable to take advantage of opportunities offered by international projects (R10.5), there is an unmistakable need for stable funding streams for health-promotion and disease-prevention programmes (R8.2, R8.4). When making decisions about how to allocate scarce resources, policy-makers would also benefit from additional tools, including policy briefs and biennial reports on population health status (R1.1, R10.4). Moreover, their oversight capabilities would be bolstered by scaling up the evaluation of ongoing programmes, including those delivered by nongovernmental organizations (NGOs) and other actors in the non-health sector (R10.2). Given the repeated calls of the EPHO Specialized Teams for better programme evaluation, it is expected that a public consultation process on research priorities (R10.3) will be initiated to promote recognition of public health as an independent discipline (R10.1) for conducting research in health and non-health services impacting public health outcomes. Similarly, capacity to undertake health impact assessment (HIA) of policies implemented outside the health sector is very limited. Interministerial committees would be the natural setting in which to nest these activities, with the National Council for Health taking the lead role (R4.1). Slovenian experts recommend, primarily, revising the organigrams of the Ministry of Health and NIJZ, in accordance with the regulatory framework, and tying accountability pathways and processes to national strategies and action plans (R8.1). There is room in the Directorate of Public Health of the Ministry of Health for setting up specific units related to emergency preparedness and response (R2.1) and environmental health (R3.1). The National Council for Health, for its part, could be redefined to coordinate intersectoral work (R8.7). This could include organizing and programming a high-level interministerial committee on population health (R4.1) and cross-cutting technical working groups (R4.2) in areas ranging from spatial planning (R3.6) to prison health (R5.3). Health technology assessment (HTA) and health-care quality assurance still need to be introduced into the system, and a lead body designated (R6.2). Meanwhile, NIJZ, especially its regional units, could work to strengthen the public health capacities of municipalities in the delivery of local policies and community- based services (R4.3). The formal establishment of a public health laboratory network, including reference laboratories (R8.5), could increase the efficiency and effectiveness of these services. fINANCING, PlANNING AND EvAluATION xvii xviii IMPlEMENTATION AND ENfOrCEMENT ClOSING rEGulATOry GAPS Shortages of human and financial resources in the public health system have impeded the full implementation of a range of planned activities. Prioritizing these activities in a national public health development strategy makes sense from the perspectives of efficiency and legitimacy. This relates specifically to the expansion of inspection capacities in the areas of environmental and occupational health (R3.2, R3.3), including key pieces of legislation, like the Restriction on the Use of Tobacco and Related Products Act. Similarly, there have been long delays in implementing some programmes, for example, those on patient safety, health-care quality (R3.4), spatial planning (R3.6), mental health (R4.7), and palliative and long-term care (R5.5, R5.7). This also applies to the roll-out of the e-health system (R9.3) and the implementation of the National Strategy for Open Access to Scientific Publications and Research Data in Slovenia 2015–2020 (R10.6). Apart from the public health benefits that would result from finally putting such programmes into place, expediting implementation could boost workforce morale, create positive momentum, and liberate the energy of professionals so that they can concentrate on new challenges. While Slovenia has an adequate regulatory framework for public health and a strong capacity for developing and approving new legislation, the passage of time has left some laws obsolete. At the same time, emerging evidence and innovations have not always been integrated quickly into the legal fabric governing the health system. Updated laws are needed to modernize the health-information system (R1.1) and the system of mandatory vaccination (R5.2), and to facilitate the creation of an official designation for public health professionals working outside the medical sector (R7.1). Amendments to rules on the provision of preventive services can help extend access to essential services in health centres, especially for vulnerable populations (R5.1, R5.3, R5.4, R5.7), as well as to non-health settings, like schools (R4.5). Furthermore, packages of targeted legislation could be prepared to fill specific gaps relating to patient safety (R3.4), environmental health (R3.2), occupational health (R3.3), behavioural and mental- health determinants (R4.6) and online sales (R3.5). Revised protocols could also improve the governance of public–private partnerships (R4.5) and collaboration with patient associations (R5.6). ACHIEvING COHESION IN PublIC HEAlTH PrOGrAMMES The evolution of public health activities in Slovenia – and worldwide – has in many cases resulted in the creation of silos, wherein individual activities develop in isolation. The absence of a national strategy that unifies actions under an agreed set of principles and objectives can result in inefficiencies, duplications, and gaps. Slovenian experts recommend working towards better coherence and comprehensiveness in broad areas, like health communication (R9.1), emergency preparedness and response (R2.2), and environmental health (R3.1), as well as in the general interface between public health and primary care (R5.1). Specific public health programmes are also needed to tackle the key social and environmental determinants of health, including occupational health (R3.3), alcohol, tobacco, sexual and reproductive health, and family violence prevention (R4.7). These should be paired with respective communication campaigns, targeting different audiences through different media (R9.2). xix Table 2 presents the recommendations, the vast majority of which it was deemed would have a substantial impact. EPHO 1. Surveillance of population health and well-being R1.1. Improve existing sources of health data and expand tools for the dissemination of health indicators R1.2. Rationalize, standardize and modernize the data-collection system in health care R1.3. Gather information on the health-care system from the patient perspective EPHO 2. Monitoring and response to health hazards and emergencies R2.1. Establish a permanent emergency-response unit in the Ministry of Health R2.2. Develop a health-sector emergency plan R2.3. Implement regular training in emergency preparedness and response through simulation exercises EPHO 3. Health protection, including environmental and occupational health and food safety, among others R3.1. Design a comprehensive strategic plan and strengthen Ministry of Health, NIJZ and NLZOH capacities for environmental health R3.2. Strengthen legislation on environmental protection and its enforcement R3.3. Improve accountability for the organization and delivery of occupational medicine R3.4. Accelerate and renew regulatory and implementation activities for patient safety and quality of health care R3.5. Ensure the safety of online sales R3.6. Strengthen intersectoral accountability for human health through guidelines on spatial planning EPHO 4. Health promotion, including action to address social determinants and health inequity R4.1. Create a high-level interministerial working group on population health R4.2. Create cross-cutting technical working groups on priority health topics, including representatives of NGOs and the private sector, when appropriate R4.3. Strengthen the public health mandate and public health capacity in regions and municipalities R4.4. Manage structures and processes for public–private collaboration R4.5. Prepare a public health legislation package, tackling the main behavioural, environmental and social determinants of health R4.6. Prepare strategic documents setting out national priorities and programme planning Table 2. recommendations (r) of the EPHO self-assessment in Slovenia xx EPHO 5. Disease prevention, including early detection of illness R5.1. Adopt a national strategy for the development of primary health care R5.2. Amend the Communicable Diseases Act R5.3. Implement key measures in prison health services R5.4. Organize rehabilitation services at all levels of health and social care R5.5. Support the implementation of planned activities in palliative care R5.6. Assess the organization, ground rules and activities of patient associations R5.7. Adopt the Long-term Care Act EPHO 6. Assuring governance for public health R6.1. Formulate a national strategy for the development of the public health system, as foreseen in the National Health Care Plan 2016–2025 R6.2. Create an independent agency for health technology assessment R6.3. Define and promote quality standards for public health services R6.4. Prepare biennial reports on population health for the Parliament EPHO 7. Assuring a sufficient and competent public health workforce R7.1. Establish a coordinated process for planning and monitoring the public health workforce through a national strategic human-resources plan R7.2. Create a national school of public health R7.3. Align workforce knowledge and skills with the current state of the art R7.4. Design training opportunities aimed at providing an understanding of public health evidence, targeted to politicians, journalists, and managers of the health and other sectors EPHO 8. Assuring sustainable organizational structures and financing R8.1. Revise the organization of the Ministry of Health and NIJZ to make it more process-oriented and aligned with the regulatory framework R8.2. Introduce a strict budget for population-based prevention R8.3. Strengthen evidence-based planning, prioritization, financing and implementation of public health activities and legislation R8.4. Introduce a stable, secure budget line for regular public health programmes run by NIJZ, independent of funds allocated for specific, short-term projects R8.5. Establish national laboratory networks, including reference laboratories R8.6. Allocate additional financial resources for public health laboratory functions R8.7. Secure the proper organization and financing of complementary public health services outside the remit of institutional public health EPHO 9. Advocacy, communication and social mobilization for health R9.1. Develop a national strategy for health communication R9.2. Regularly implement awareness campaigns to educate the general population and professionals from non-health sectors on public health matters R9.3. Foster the national implementation of e-health solutions EPHO 10. Advancing public health research to inform policy and practice R10.1. Establish public health as an independent research field in the national classification system of the Slovenian Research Agency R10.2. Establish a monitoring system to evaluate public health policies and programmes, including those delivered outside the public sector R10.3. Develop a platform for coordinating and disseminating public health research R10.4. Invest in advocacy tools to facilitate the advancement of public health policies and programmes R10.5. Scale up Slovenia’s involvement in international and European activities in the field of health R10.6. Strengthen implementation of the National Strategy for Open Access to Scientific Publications and Research Data in Slovenia 2015–2020 xxi © Boris Keber © NIJz Introduction In 2012, the WHO Regional Committee for Europe endorsed the European Action Plan on Strengthening Public Health Capacities and Services (2012–2020) (EAP-PHS) (1) to maximize opportunities for promoting population health and well-being, reducing health inequities, and strengthening public health through an equitable, sustainable, and high-quality, people- centred health system. One of the routes to the executive promotion of the goals and objectives of EAP-PHS (1) is through baseline self-assessments of the current strengths and weaknesses of public health capacities and services carried out by Member States. The self-assessment tool for the evaluation of essential public health operations in the WHO European Region (hereafter, the EPHO tool (2)) provides Member States with the opportunity to assess their own strengths, capacities and organizational resources, as well as their implications for the workforce. It also facilitates the identification of areas for development and action at the national level, and priorities for public health development across the European Region. The Ministry of Health of the Republic of Slovenia (hereafter, the Ministry of Health) and the WHO Regional Office for Europe (hereafter, the Regional Office) have a long history of productive collaboration, targeting common priorities for health and its determinants to promote health and sustainable development in Slovenia. In support of the Resolution on the National Health Care Plan 2016–2025 “Together for a society of health”(3), in 2017, the Ministry of Health, in collaboration with the Regional Office, initiated a self-assessment of essential public health operations (EPHOs) in Slovenia. The aim of the self-assessment was to support the strengthening and modernization of the public health services in the country and improve the quality and coverage of public health services and capacities, in line with EAP-PHS (1). The objectives of the self-assessment within the national context were to: • achieve a shared understanding of the services encompassed by EPHOs; • generate the empirical evidence necessary to identify strengths and weaknesses, and substantiate key recommendations for action; • foster consensus on priority recommendations and translate the output of the process into actionable recommendations. The expected outcome of the self-assessment was that it would: • generate conclusions and recommendations for future action that could feed into policy practice and public health reform; • through the adoption of a participatory approach during the process, trigger dialogue and reflection, and foster improvement; • promote consensus on a core set of prioritized recommendations, as well as the achievement of a social licence by ensuring the community’s acceptance of its results. 1 2CORE EPHOs SERVICE DELIVERYINTELLIGENCE ENABLER EPHOs VISION: Sustainable health and well-being Clustering of Essential Public Health Operations (EPHOs) - to deliver Public Health services Health promotion Health protection Disease prevention Governance EPHO 6 Public health workforce EPHO 7 Funding EPHO 8 Communication EPHO 9 Research EPHO 10 Monitoring Informing health assessments and plans EPHO 4 EPHO 5EPHO 3 EPHOs 1 + 2 Surveillance Methodology The assessment was based on the EPHO tool (2), designed to guide the broad self-evaluation of all public health operations within Member States in the WHO European Region. EPHOs are separated into 10 broad categories: 1. surveillance of population health and well-being; 2. monitoring of and response to health hazards and emergencies; 3. health protection, including environmental and occupational health and food safety, among others; 4. health promotion, including action to address social determinants and health inequity; 5. disease prevention, including early detection of illness; 6. governance for health and well-being; 7. public health workforce; 8. organizational structures and financing; 9. advocacy, communication, and social mobilization for health; 10. public health research to inform policy and practice. Fig. 1 illustrates the interaction between them. fig. 1. Clustering of EPHOs to deliver public health services Source: WHO Regional Office for Europe, 2015 (4). 3EPHOs have proven to be a practical instrument both for promoting a harmonized understanding of public health throughout the Region and for renewing public health in line with the precepts of Health 2020 (5) and EAP-PHC (1). The process of assessing EPHOs involves a broad spectrum of public health actors, both within and outside the health sector, as well as a participatory and systematic approach. It requires professionals from different sectors and fields of expertise to come together in interactive group work to pave the way for the adoption of a whole-of-government, whole- of-society approach to refine national public health services. Fig. 2 provides a visual aid of the self-assessment process in Slovenia, illustrating the elements of the journey, which the self-assessment teams needed to consider before arriving at their recommendations and proposing action to meet them. This participatory approach triggers and stimulates discussion on mutual challenges and collaborative problem solving. Wide participation throughout the process helps to embed public health concepts into institutions across government and society, marking a path towards better intersectoral cooperation. The organizational structure adopted throughout the EPHO self-assessment process in Slovenia was based on the guiding principles endorsed in the EPHO tool (2) that were adjusted to the national context to secure maximum impact. These guidelines envisaged the identification of the key stakeholders and their engagement in the assessment and planning process, a key outcome of the early stages of the self-assessment. Fig. 2. Visual aid of elements to be considered in an EPHO self-assessment © Anne Madsen/Status Flow. Based on the roles required by, and the allocation of responsibilities foreseen in, the EPHO self-assessment process, the following teams were established: the Core Secretariat, the Oversight Committee, the Advisory Committee, and the Specialized Teams. The Oversight Committee was composed of senior officers in the Ministry of Health, the Head of the WHO Country Office in Slovenia, and senior representatives (directors) of key public health institutions in Slovenia. The Core Secretariat comprised WHO experts, the national coordinator of the process, and a resident physician. For each EPHO, the Oversight Committee designated a specialized team leader; the leaders of EPHOs 4 and 5 also nominated sub-EPHO coordinators. The leaders were responsible for designating the members of the Specialized Teams, ensuring that they represented a diversity of perspectives, and eliciting the opinions of all of them. For EPHOs 7 and 8, Slovenia engaged two international experts, Professor Vesna Bjegović Mikanović (Belgrade Medical University, Serbia) and Professor Peggy Honoré (Louisiana State University, USA), to help guide the process and provide meaningful input in the areas of public health workforce and public health financing. The Self-Assessment Process Coordinator systematically coordinated and monitored the quality of the work performed by most of the Specialized Teams. This included ensuring adherence to timelines and the production of deliverables, intervening as appropriate to address any quality concerns, and liaising with the Core Secretariat on matters of quality assurance and process milestones. The process of assessing EPHOs in Slovenia consisted of three separate phases: (i) the preparatory phase; (ii) the data-gathering and analysis phase; and (iii) the prioritization, action-planning and follow-up phase. Between September 2017 and January 2018, several workshops and meetings of the Specialized Teams were held to complete all tasks, collect data and gather the information required in the EPHO self-assessment process. This publication presents a summary of the main findings relating to each EPHO, and an overview of the strengths and weaknesses of public health services across the country. These constitute significant elements that the national public health services could utilize to monitor progress and further enhance the delivery of public health services. It also provides background evidence and information to support the implementation of EAP-PHS (1). 4 © NIJZ

© Aleš Fevžer KEy fINDINGS Of THE EPHO SElf-ASSESSMENT IN SlOvENIA EPHO 1. Surveillance of population health and well-being See: EPHO 1 recommendations EPHO 1 deals with the quality of the health-information system, that is, the system used for collecting, monitoring, and analysing data on health and the health system, and for transforming the results into information that can be used to guide policy decisions. The health system uses a range of data sources and tools, including the civil-registration and vital- statistics systems, health-related surveys, the health-management information system and disease registries. Health data sources and tools In relation to the surveillance of population health and well-being, there is a clear legal framework and rich sources of comprehensive health data, namely, NIJZ, the Health Insurance Institute of Slovenia (ZZZS) and the Institute of Oncology (Cancer Registry of the Republic of Slovenia (6)). Provided certain conditions are met, personal identity numbers allow these data to be linked with those of other databases and registries within and outside the health system, for example, the Central Population Register (7). The system also enables versatile analyses, based on different variables of interest, including regional and some socioeconomic inequalities. Standardized methodologies allow national and international comparisons and help to ensure the quality of data collection, while annual quality audits identify problems. Slovenia also has long-standing experience in maintaining disease registries, the Cancer Registry (6) standing out as one of the best in the world. Centralized and local IT systems are due to be upgraded, with some important areas of health data still relying on paper-based reporting systems. In particular, the legally mandated implementation of e-certification of cause of death is still pending. The Healthcare Databases Act (8) is outdated and does not correspond to the requirements of the health system. There is a need to reach political and legal consensus on which health registries and databases should be expanded to achieve a more comprehensive coverage. The lack of mechanisms for the sustainable funding of population surveys threatens the regularity of existing surveys and hinders the implementation of others. Strengths Areas in need of further improvement 7 A good legal framework and experience render the existing surveillance systems quite effective. Many systems are linked to allow better analysis of related information. Standardized methodologies help to ensure comparability at the national and international levels, and there are good examples of intersectoral collaboration (for example, between NIJZ and the Agency for Road Safety). Strategic documents have also set the stage for better analysis of the social determinants of health. There are ample data on health accounts, defined by EU Regulation 2015/359 (9) and the System of Health Accounts manual (10). The legal framework is adequate, and several different registers, databases and surveys provide reliable and comparable data on the workforce, service utilization, financing, and infrastructure in the health sector. Recently, great efforts and progress have been made in the area of patient-reported experience measures (PREMs). Hospital and outpatient PREMs surveys are carried out on an annual basis. NIJZ is involved in an international OECD project on developing PREMs and patient-reported outcome measures (PROMs) instruments for the mental-health services and patients with chronic conditions managed at the level of primary health care. full implementation of the Central registry of Patient Data could improve the quality of many statistics (for example, on morbidity, preventive check-ups in children and adolescents, biological risk factors, like glucose, and NCDs, such as cardiovascular disease and mental health). Outpatient data represent one of the areas most in need of improvement. These data are available only in aggregate form, limiting opportunities for data linkage. The long time lag before they are made available undermines a timely response to changes in the use of health-care services. Technical, legal and compliance issues impede data linkage between some sources. Further efforts are needed to bolster intersectoral collaboration. Communicable diseases are underreported in health centres. This section covers the main areas of the health information collected, such as cause-specific mortality and morbidity, communicable diseases and noncommunicable diseases (NCDs), maternal and child health, immunization coverage, and health inequalities. This section investigates available information on health-system performance, including financing, workforce, user experience, access to essential medicines, and cross-border health. Surveillance of population health Surveillance of health-system performance 8 Strengths Areas in need of further improvement Strengths Abundant data are available, for example, through annual statistical reports, NCDs monitoring reports, compliance with IHR (11), and some health-sector analyses. There are also technical and legal possibilities of integrating and analysing data from different sources. Slovenia also participates in the WHO Evidence-informed Policy Network and is introducing health-system-performance analysis with the support of the European Commission. Public health professionals at NIJZ produce most of the health data, and all policy and legislative proposals must be justified with evidence and data. NIJZ works closely with the Ministry of Health, which provides information on the priorities for health policy and analysis. There is no dedicated institution for monitoring the quality of the health system and performing health-system-performance assessments despite NIJZ’s general mandate to monitor health care. Situation analyses are reactive rather than proactive and usually driven by and limited to the scope of the policy document being developed. Priorities shift quickly, limiting the time available for rigorous analyses of health data on specific issues. This section focuses on the treatment of health data, namely, whether they are subject to global analysis or destined for decision-makers as useful and timely information. It also covers international reporting commitments, for example, those related to the implementation of the International Health Regulations (IHR) (11). Data integration, analysis and reporting 9 Strengths Areas in need of further improvement © NIJZ The most important area in need of improvement is monitoring of patient experiences. At present, data are available only for adult inpatients, but not for outpatient care or long-term care. The expertise of NIJZ and clinical experts could be better leveraged to guide work in this area under the direction of the Ministry of Health. Agreement should be reached on the use of a uniform set of national questionnaires for each level of health care (hospital, outpatient, primary health care). Another major shortcoming is the lack of information on the impact of different services, making it impossible to determine the effectiveness of programmes in meeting their objectives. Areas in need of further improvement 10 EPHO 2. Monitoring and response to health hazards and emergencies See: EPHO 2 recommendations EPHO 2 is concerned with emergency preparedness and response. This includes specific systems for monitoring and reducing risks and for preparing for, mitigating, and responding to health emergencies. This group of activities is conceptualized according to the all-hazards/one-health paradigms. • The all-hazards approach says that while hazards vary in source (natural, technological, societal), as they often challenge health systems in similar ways and require similar types of action, they should be organized according to the same model. • The one-health approach recognizes that interactions between humans, animals and plants in their shared environment make it necessary to take transdisciplinary and multisectoral action to ensure better health for all. This section focuses on the risk assessment and monitoring of health hazards. Identification and monitoring of health hazards The Administration of the Republic of Slovenia for Civil Protection and Disaster Relief (URSZR) is a strong, consolidated organization with a well-established system of identifying and monitoring the most important health hazards, including all the core capacities needed for the response. Slovenia follows the international guidelines, including the European Union (EU) Early Warning and Response System (EWRS) and IHR (11). There are national and regional focal points for cross- border threats, good laboratory capacities, and legally defined surveillance and reporting systems for communicable diseases. The workforce – though small – is characterized by high levels of training, professionalism, and capacity for collaboration. There is a lack of cohesion between different plans and standard operating procedures (SOPs) as these are developed individually rather than under a unified general plan for public health. This may undermine coordination during a public health emergency. There is a chronic shortage of human and financial resources for emergency preparedness, especially in the public health sector. Chemical risk assessment is not performed systematically and is often outsourced. This method is unpredictable and leaves Slovenia vulnerable to unforeseen events. The Ministry of Health’s security programmes and strategies lack development, particularly with regard to multisectoral coordination. The electronic infrastructure is outdated, which poses problems for connectivity and timely response. Strengths Areas in need of further improvement 11 This section deals with the core capacities, systems and services needed to respond to an emergency and mitigate damages, including the institutional framework, the health-sector emergency plan, coordination structures, warning systems and critical response services. This section deals specifically with the implementation of IHR (11). Preparedness and response to public health emergencies Implementation of IHr URSZR is the backbone of Slovenia’s emergency-response system. Its strengths include: a clear regulatory framework; well-defined responsibilities, according to the severity of the event and its associated risks and geographic scope; a multisectoral committee; a well-trained workforce; established lines of communication at the national, regional and local levels; and a lead role in institutional risk communication. Alert systems are in place for specific disease outbreaks and emergencies, and the health sector has developed a range of rigorous emergency plans for specific areas. Most capacities detailed in IHR (11) are in place, including: a national focal point and epidemiologist on call 24/7; protection, alert and medical services at points of entry and along transportation channels (for example, ship-sanitation control); ambulance units; and annually verified stockpiles of critical supplies (for example, drugs, vaccines, protective gear). The area of communicable diseases is well covered, with operational guidelines for non-medical staff, a legal basis for notification and reporting, and SOPs for safe transport in ambulances. A pool of experts has been identified for all sectors, and there is good cooperation at the European (EWRS, European Centre for Disease Control) and global (WHO) levels. There is no full-time emergency preparedness and response unit in the Ministry of Health. This hinders the adoption of an all-hazards approach as there is no institutional framework to ensure coordination between the different areas of the health system. The lack of a crisis-communication plan – together with the absence of IT support or regular risk-communication training – undermines the ability of the authorities to deliver accurate information quickly during an emergency. The functionality of existing plans and strategies remains untested. Public health preparedness – including that for points of entry, chemical events and radiation hazards – would benefit from additional exercises. Scant human and financial resources greatly limit the capacity for a surge response and intersectoral planning and coordination efforts. There is no legally binding document establishing responsibilities or funding for IHr implementation. This has resulted in some gaps in the implementation of core activities. understanding of IHr (11) is incomplete in many non-health sectors, which hinders their awareness of the need to communicate public health threats to national focal points. Except in the case of communicable- disease threats, there is no established system of multidisciplinary cooperation at the state level, nor recognition of the central role of the national focal points in collecting and communicating risks of international concern. Strengths Areas in need of further improvement Strengths Areas in need of further improvement 12 EPHO 3. Health protection, including environmental and occupational health and food safety, among others See: EPHO 3 recommendations EPHO 3 deals with the institutional capacity to develop regulatory and enforcement mechanisms to protect public health and the environment. Specific areas addressed include environmental and occupational health, food safety, patient safety, road safety and consumer-product safety. Environmental health protection Occupational health protection All major stakeholders are publicly committed to protecting the environment and advancing the goal of a sustainable, low-carbon economy. An effective legislative framework is in place in the areas of outdoor air and water, along with legal measures to incentivize the use of renewable energy. Risk assessment procedures (for example, in laboratories) are of good quality, and there is good informal cooperation between different institutions and stakeholders. The National Programme of Health and Safety at Work 2018–2027 (12) recognizes occupational health and safety as the foundation of any efficient economy, providing a good political basis for further action. There are also adequate, EU-compliant regulations in many areas, including risk assessment, preventive check-ups, workplace accidents, and asbestos-related diseases. Some regulations require professionals to perform workplace risk assessments and carry out biomonitoring. There are regulatory gaps in the areas of urban-wastewater recovery, soil contamination, remediation of excessively polluted sites, indoor air, building codes, noise, and odour and vibrations. There are few formal intersectoral communication channels for ensuring coherent action on environmental accidents and/or threats related to climate change. The information system for environmental health has limitations in terms of risk-assessment capacity, sustainable funding, sufficiency of human resources, and linkages with the rest of the health-information system. The development of some regulatory areas (for example, rules on Occupational Diseases) has stalled. There are shortages of financial, laboratory, human and information resources, especially for human biomonitoring. The high costs of health and safety measures, plus a lack of awareness among employers about their responsibilities, hinder employer action to protect workers’ health. Strengths Areas in need of further improvement Strengths Areas in need of further improvement 13 food safety Patient safety Food safety is well covered with up-to-date, EU-compliant legislation; independent, systematic monitoring by highly qualified personnel; and communication and collaboration among all stakeholders. There is evidence of strong points in patient safety. Hospitals have quality- and safety-assurance structures, and efforts are ongoing to establish or implement different tools, like clinical pathways, quality indicators, a system for monitoring sentinel events, patient- and community-tailored treatments, and patient empowerment. Professional training on quality and safety is available. The information system lacks a common and accessible database for risk-assessment and scientific evidence. There are no quality-assurance mechanisms for the public procurement system (for example, in connection with school meals). Overall, patient safety is ensured only through a patchwork of regulations and norms – there is no comprehensive regulatory basis or research base to underpin the quality of health care. As a result, the responsibilities of the institutions are poorly delineated, and activities are not systematic or unified under a common strategy. The lack of a budget line for quality-assurance activities in health- care centres entails funding shortages. Many activities and documents are pending completion or implementation, including the proposed act on quality and safety in health care, activities of the EU Structural Reform Support Service, and governmental projects to reduce adverse events of medical treatment and modernize the system for reporting adverse events. Strengths Areas in need of further improvement Strengths Areas in need of further improvement Workplace risk assessments may be undermined by conflicts of interest among employers who are responsible for commissioning them. There is insufficient cooperation between professionals in public health and those in occupational, transport and sports medicine. road safety road safety is well covered. This includes: the explicit commitment of all major stakeholders; a national programme on road safety; up-to- date, EU-compliant legislation; independent, systematic work by the Public Agency of the Republic of Slovenia for Traffic Safety; and good cooperation among stakeholders. The databases on traffic accidents and injuries (managed by the Ministry of the Interior) and the health statistics on traffic-accident injuries (managed by NIJZ) are not connected. Strengths Areas in need of further improvement 14 Consumer-product safety Consumer-product safety is underpinned by a strong, EU-compliant regulatory framework, which was developed and implemented in collaboration with all major stakeholders. There is an effective reporting and recall system for unsafe products, as well as regulations for prohibiting trade and introducing sanctions, if necessary. Laboratories for assessing the risks of different products are well equipped, if understaffed. Due to cross-border implications, online sales are entirely unregulated, and measures to protect consumer safety in this area are completely ineffective. funding for risk assessment is unstable, which has an especially strong impact on regular staff numbers. Strengths Areas in need of further improvement © Alenka Černe 15 EPHO 4. Health promotion, including action to address social determinants and health inequity See: EPHO 4 recommendations This EPHO is defined by its intersectoral nature with particular emphasis on health equity and social determinants. Its suboperations address some of the most important and complex threats to public health, requiring the input of broad coalitions of actors. The intersectoral and interdisciplinary capacity of the Ministry of Health affects its ability to influence and work with different stakeholders at the government, community and private-sector levels. Intersectoral and interdisciplinary capacity Intersectoral collaboration is strongest among government agencies and ministries. The Ministry of Labour, Family, Social Affairs and Equal Opportunities (MDDSZEM) and the Social Protection Institute are tasked specifically with addressing inequalities, while recent Ministry of Health plans explicitly support intensifying intersectoral measures. Government reports provide periodic analyses of socioeconomic determinants of health. In addition, intersectoral working groups on areas like drugs or road-traffic safety have been set up, as well as interministerial groups charged with preparing legislation and strategic policy documents. There is extensive interdisciplinary collaboration between NIJZ and NLZOH and professional institutes and agencies, for example in the areas of environmental health, health equity, accidents and injury prevention. Positive examples of cooperation with community actors and NGOs include health-promotion programmes carried out by NIJZ, and Ministry of Health grants provided to NGOs for community work. Regarding interactions with the private sector, there are laws that provide protection against corruption along with transparent processes that safeguard compliance. Intersectoral cooperation at the national and local levels is not formalized, despite existing legislation, and often depends on individual interest. There are no systematic HIAs. local authorities have no guidance regarding community-health promotion even though they are a legally obligated to promote well- being. The norms governing private-sector activities that impact health are somewhat rudimentary, for example, activities related to occupational health, and there are few positive examples of cooperation with industry on health matters. Strengths Areas in need of further improvement This section examines government and health-system responses to the behavioural, environmental and social determinants of health and associated risk factors. Given the centrality of the health-promotion services in addressing these issues, details of their strengths and weaknesses, along with the relevant self-assessment scores, are given in Table 3. 16 Strengths Areas in need of further improvement Tobacco (score: 8/10) Comprehensive, up-to-date legislation. Ongoing efforts to increase funding through NGOs. First national tobacco strategy. Tobacco remains cheap and accessible. Lack of intersectoral programmes. Lack of national media campaigns. Alcohol (score: 6/10) Drink–driving policies and countermeasures. Specific activities related to the protection of young people (for example, measurement of alcohol content in young drivers, bans on sales of alcohol). Monitoring and surveillance. Measures related to health-services response. Ongoing efforts to increase funding through NGOs. No national strategy on alcohol control. Few marketing regulations (no sales-licensing system, no price controls, incomplete marketing restrictions, no excise taxes on wine). Weak enforcement of existing laws. Little activity in evidence-based health promotion, prevention or treatment. Little being done to reduce the public health impact of illicit and informally produced alcohol. Nutrition (score: 7/10) Well-developed national policy framework with multisectoral commitment to objectives. Formally established guidance on breastfeeding and nutrition in infancy and early childhood. Effective collaboration with schools (lunch programme, nutritional education, vending machines). Nutritional guidelines for active and elderly populations. Implementation of activities cannot be adequately monitored. Cooperation with private sector is weak and threatened by vested interests. Lack of job security for working mothers can affect breastfeeding and thus threaten infant nutrition. Suboptimal coordination of nutritional activities in health system; there is a need to digitalize data on breastfeeding and nutritional status in children and young people. Incomplete assistance for adult and elderly populations (fruit and vegetable subsidies). Table 3. Health policy addressing core health determinants and associated risk factors Addressing the behavioural, social and environmental determinants of health through a whole-of-government, whole-of-society approach 17 Strengths Areas in need of further improvement Physical activity (score: 7/10) National Programme on Nutrition and Physical Activity for Health, with cross- sectoral implementation. Long tradition of and ongoing activity on promoting physical activity in primary-care and school settings. Effective monitoring of children’s physical fitness (SLOfit systema) Underfunding of sports programmes, especially for vulnerable populations and young people. Staff shortages (kinesiologists and physiotherapists) in community PHC centres. Poor capture of electronic data. Unclear pathways to implementing national programmes at the local level. reproductive health (score: 7/10) Existence of regulatory framework. Availability of comprehensive reproductive services. Qualified staff. Problems in accessing gynaecological services. Problems in accessing testing for and treatment of sexually transmitted infections. Suboptimal organization of preventive programmes in the field of reproductive health. Unsystematic sex education or sexual health promotion. No centre for treating victims of sexual violence. Substance abuse (score: 7/10) Comprehensive, evidence-based approach to treatment for substance abuse. Articulated network of addiction services and harm-reduction programmes. Good access to treatment (for example, for HIV) and opioid substitutes. Good data-collection across the European information network on drugs and drug addiction and the national network. Shortages in human and financial resources impeding the development and maintenance of networks. Acute deficits in investments in prevention and education programmes for professionals and the population. Lack of programme/process evaluations; funding, therefore, not based on programme effectiveness. Mental health (score: 4/10) Resolution on the National Mental Health Programme 2018–2028 (RNMHP) (13). Range of legal acts and programmes supporting mental-health services, including screening and school counselling. Increasing recognition of mental-health issues in society. Specific examples of best practice that could serve as models countrywide. Manager or coordinator of RNMHP 2018–2028 not yet appointed. Shortages in specialized staff. Gaps in institutional services (for example, psychotherapy, secure paediatric wards). Insufficient primary-care and community services. Lack of epidemiological research. a SLOfit is a national surveillance system for physical and motor development of children and youth in Slovenia. 18 © NIJZ Strengths Areas in need of further improvement violence (score: 7/10) Good network of multisectoral services to protect survivors of domestic violence. No recognition of violence as a public health priority. Lack of integration in schools (teacher training, gender-equality programmes). No linkage of violence-related information with the justice system. Limited availability of health data. Injuries (score: 7/10) A range of legal acts and international-, national- and community-level, cross- sectoral prevention programmes (for example, on children and adolescents, traffic, poisoning, chemicals). Good information system for monitoring injuries. Need to strengthen cross-sectoral cooperation in certain areas (for example, home injuries, falls, drowning). Lack of articulation between individual departments and processes, especially in the area of chemicals. Shortage of human and financial resources, for example, for safety promotion. No programmes on rehabilitation in the home environment for injury victims. Social determinants (score: 8/10) Long tradition of work on socioeconomic determinants and health inequalities, and numerous ongoing activities. Reliable and representative data sources. No governance mechanisms for intersectoral response to health inequalities. Gaps in data and programme coverage for vulnerable groups (precariously employed, unemployed, school dropouts). Sustainable funding not guaranteed. 19 EPHO 5: Disease prevention, including early detection of illness See: EPHO 5 recommendations EPHO 5 deals specifically with public health services based within the health and health-care systems that focus on the prevention and early detection of disease and on ensuring that patients can live with and manage their illnesses. Primary prevention includes immunization, health counselling, and other health services aimed at preventing illness, such as programmes on maternal and neonatal health or smoking cessation. Primary prevention Primary-prevention activities are regulated by a robust legal framework, governing vaccinations, health counselling, compulsory health insurance (also for the hardest-to-reach populations), and preventive examinations, with specific norms for children and adolescents, adults, women, and the working population. One staff member of the Ministry of Health is tasked specifically with managing the needs of legal migrants, minorities, people experiencing homelessness and other vulnerable populations at the system level. NIJZ and its regional units maintain fluid links with primary-care services, which facilitates education and counselling interventions. Prison health is also part of the public health network. Prenatal screening and services are widely available and, in addition to family-medicine specialists, paediatricians, gynaecologists and dentists work at the primary-care level. vaccination coverage is relatively good, although there are some challenges, namely: • the lack of effective enforcement measures for mandatory immunizations; • poor uptake (particularly among private providers) in the electronic Register of Vaccinated Persons; • the lack of an operating vaccine-related adverse events review committee; • the absence of strategic communication; • an increasing anti-vaccination lobby at the national and European levels; • individual financial barriers to the delivery of hepatitis A and B vaccinations in prisons; • a low rate of immunization against influenza among health professionals; • few vaccine-advocacy activities in primary-care centres or communities. There is little emphasis on the role of clinicians in delivering public health services. Clinicians receive limited or no systematic training in applying public health approaches to their interactions with patients, nor is their knowledge on health determinants monitored. Strengths Areas in need of further improvement Health education and promotion in community health centres are insufficient. The public is mostly unaware about health-education and promotion centres, and there is little printed health-education material available. In spite of robust preventive programmes, there are still some gaps in the provision of preventive services for different groups, including vulnerable groups (due to lack of motivation or information), young people (where sounder programme governance and management are needed), pregnant women under 35 (due to the cost of screening for congenital anomalies) and children born outside Slovenian hospitals (lack of screening programmes). Some preventive programmes (for example, on NCDs) are unevenly implemented countrywide, while others (for example, on oral health) are systematically unavailable for adults. Generalized shortages of human resources undermine service capacity. There is a need to take full advantage of emerging opportunities for cooperation with the private sector. 20 This section covers population-based disease-screening programmes and a few basic quality criteria, together with disease-awareness programmes for early detection (for example, for melanoma skin cancer) and the provision of chemoprophylactic agents to control risk factors for disease (for example, blood-pressure medication). Secondary prevention Centrally managed, well-regulated, population-based screening programmes (rules updated in 2018), with relatively good coverage, exist for breast cancer (coverage > 70%), cervical cancer (> 70%) and colorectal cancer (60%). The programmes follow European standards and have shown public health benefits; they are linked to respective registries, as is the screening programme for families affected by hereditary cancer. Activities to promote awareness about the relationship between sun exposure and skin cancer take place in schools, and there are clear recommendations on providing preventive medicines to those with defined risk factors for disease. Access barriers to cancer screening affect some high-risk groups (for example, people with no compulsory health insurance). Activities to promote awareness about the dangers of sun exposure are not continuous or systematic and the early detection of skin cancer is hindered by long waiting lists for appointments with dermatologists. The use of preventive drugs to control disease risk factors is not equally exploited. This is, in large part, due to the unequal awareness among the population about risk factors for NCDs, and about the possibilities that exist regarding use of the services. Strengths Areas in need of further improvement 21 This section focuses on services for fostering good quality of life for those living with disease, including support for patient groups, rehabilitation, survivorship, and disease-management programmes. This section relates to social systems that create an environment supportive of behavioural change and caregiver assistance at the psychosocial level. Tertiary/quaternary prevention Social support Comprehensive rehabilitation services are well organized at the tertiary level and delivered in specialized centres to all Slovenian citizens. Work in the field of palliative care is ongoing: there is a national strategy and programme, as well as an expanded professional board of palliative medicine. Opioid medications are available to anyone who needs them, and formal training in palliative care is part of the compulsory curriculum for medical students. Regarding patient empowerment, an example of one of several programmes is the Diabetes Management Strategy, in accordance with which a network of patient counsellors has been set up to assist people with diabetes. There are numerous examples of high-quality programmes on supportive environments, especially in the educational sector. These include the School Fruit Scheme and the Healthy Lifestyle Project, which focus on nutrition and physical activity, respectively. These programmes are complemented by health-promotion activities in schools and at the workplace. Regarding home care, legal and financial protection is in place for informal caregivers of people with disabilities. rehabilitation services could be better integrated at the primary and secondary levels of health care, social care and education. There is a need for clinical guidelines and defined patient pathways for referrals between services. Especially in rural areas, palliative care and home help are not always available. Patient-support groups have unequal capacity, depending on the disease or condition, differential resource availability, and participation. Many are financed by pharmaceutical companies. The implementation of documented good practice is slow (sugar- sweetened foods and beverages tax, high alcohol tax, etc.). The legal protection of informal caregivers does not extend to those caring for people who are not disabled. There is no systematic education, training, and support for caregivers, including those providing respite care. It is often difficult for relatives to find the human and financial resources they need for dependent care. Strengths Areas in need of further improvement Strengths Areas in need of further improvement 22 EPHO 6. Assuring governance for public health See: EPHO 6 recommendations EPHO 6 on governance is cross-cutting; it touches upon issues, such as leadership, management, accountability, planning, implementation, monitoring and evaluation, all of which are essential ingredients for the success of any vertical programme. This section deals with the commitment of the national Government to improving population health and the capacity of the Ministry of Health to lead public health efforts within and outside the health system. leadership for a whole-of-government, whole-of-society approach to health and well-being Slovenia’s Constitution (1992) guarantees the rights of the population to health and universal health care. Numerous international projects at the regional and European levels, for example, in collaboration with the European Observatory on Health Systems and Policies, the European Commission and WHO, reflect Slovenia’s active participation in developing international public health evidence. Numerous recent initiatives at the national level, including the Slovenian Development Strategy 2030 (14) and the National Health Care Plan 2016–2025 (3), illustrate growing momentum in advancing public health. The governance and management of public health services are well integrated into the Ministry of Health, and a strong nongovernmental sector has been established. Intersectoral work is especially strong in the areas of nutrition, physical activity, road safety, food and water safety and the environment, with some good examples in other areas. The Pomurje region has the longest tradition in linking health and development with a regional development strategy that has used the Health-in-All-Policies (HiAP) approach for over a decade. Public health managers are not prepared for modernizing public health processes. There is little training available for non-medical professionals or managers, few professionals can carry out HIAs, and there are limited opportunities to use public health evidence in policy- making. Intersectoral action is limited to a few areas; it is not systematically reported to the Parliament or the public, or promoted at the central level. Professional networks in public health have no institutional nexus that would attract the entire public health community, making it difficult to obtain a critical mass of professionals to counterbalance the influences of other interest groups. This section covers stakeholder participation, situation analysis, planning, implementation, and the monitoring and evaluation of health policy, at both the general and specific levels. Health-policy cycle Strengths Areas in need of further improvement 23 This section deals with the Ministry of Health’s capacity to influence government policy through the development of public health legislation, HIA and HTA performance, and compliance with the EU community-health-services system. regulation and control Formal structures and mechanisms of public health policy-making are mostly in place, including those related to stakeholder involvement, situation analysis, the preparation of strategic documents, and implementation and evaluation. Partnership with international bodies has been very beneficial in terms of harmonizing international evidence and national policies. The implementation of strategic plans is generally supported by a defined national oversight body, while reporting requirements and predefined indicators constitute the basis for evaluation and ensure transparency. Slovenia has a well-established, transparent, functional system of proposing, developing and adopting legislation, which is mostly aligned with international health treaties. Efforts in intersectoral collaboration and the preparation of decision-making aids, like policy briefs, are increasing, and there is general support of HIAs among professionals in the Ministry of Health. In terms of the ongoing monitoring and control of services, there are some good examples (for example, assessment of screening programmes). Specific national strategies are also increasingly integrating process (and some outcome) indicators into the reporting requirements. Stakeholder involvement is often nominal since institutional representatives are not compensated for their contributions nor are they incentivized to make them. There are obstacles to evidence-based policy-making, including limited workforce capacities in knowledge brokering, the lack of a national health report on population health in Slovenia, and gaps in the availability of and linkage between health and related data. There is no national strategy for the development of public health services, which would combine and harmonize individual programmes, although the self-assessment should provide a basis for rectifying this situation. Changes in the political landscape can result in shifting priorities, undermining the implementation and follow-through of approved plans. This is especially problematic regarding intersectoral collaborations and agreements. There is very limited capacity for assessment of health-services performance; no independent institution is responsible for such activities. HIAs are not systematically applied to draft legislation with a potential impact on health, and the use of HTAs for evaluating new treatments is rare. Policy briefs exist only for isolated areas (for example, tobacco control, alcohol policy, antimicrobial resistance). little guidance is available on the implementation of public health measures, and indicators for measuring impact are generally lacking. Strengths Areas in need of further improvement Strengths Areas in need of further improvement EPHO 7. Assuring a sufficient and competent public health workforce See: EPHO 7 recommendations EPHO 7 assesses capacities for planning, managing, educating and governing the public health workforce. This section assesses the extent to which countries can: 1) understand the current workforce supply; 2) anticipate future demands; 3) develop and implement their human-resources plan; and 4) monitor and evaluate the roll-out, adapting action as needed. Human-resources development cycle The national database on health-care providers and workers covers an important share of the data needs relevant to the public health workforce. This database is constantly updated and is connected to the Register of the Slovene Medical Chamber. Moreover, there is formal policy recognition (for example, through the Resolution on the National Health Care Plan 2016–2025 (3)) of the need to strengthen strategic health-workforce planning. One ongoing EU-funded project in this area, led by NIJZ, is the Planning and Management of the Public Health Care Service Network, which aims to improve the planning and management of the health workforce, with a special focus on paediatrics, surgery, orthopaedics and gynaecology. Tools developed in this project will also be used for planning in other professional areas of health care, as well as in public health. 24 Strengths © Alenka Černe Chronic and system-wide workforce shortages threaten Slovenia’s capacity to deliver public health services. The self-assessment revealed major deficits in the following areas, among others: • emergency preparedness and response (especially risk assessment, toxicology and ecotoxicology) • health communication • substance-abuse programmes; • mental-health programmes • palliative care and home care • quality assurance • research, especially health- services research 25 Areas in need of further improvement • planning and governance activities • public health inspection and enforcement agencies • laboratory systems • occupational health • primary- and secondary- level health centres • safety promotion • rehabilitation services. Health and public health workforce planning is not a systematic or participatory process that addresses population needs, and there are no designated government structures in charge of human-resources planning and management. This represents a major threat to system sustainability. There are gaps in data availability (health-workforce data on emigration/immigration, retirement, and employment in other sectors) and a lack of connectivity between existing databases (health-care providers, students in health fields). There is no definition of a public health worker. The formal category of “public health specialist” exists for medical doctors and dentists who graduate from a four-year post-graduate residence programme; all other public health professionals are “unclassified”. 26 Human-resources management includes developing organization and human-resources policies, recruitment and retention strategies, human-resources, and financing. Three areas of public health education are covered: 1. institutional strength, rigour and innovation; 2. preparation of an adequate workforce to implement national health strategies; and 3. appropriateness of public health curricula at all educational levels. Human resources management Public health education Strong regional competences represent an asset for human-resources management in that the regions work to develop a local public health workforce in line with their specific public health programmes. Examples include programmes to tackle harmful drinking, mobile units for addiction prevention and harm reduction, communicable- disease surveillance and control, and health promotion in primary-care settings. Another initiative for building human-resources capacity has been to allocate funding (€4 million in 2017) for tenders from public health programmes to NGOs. This measure has enabled the hiring of new staff and provided training for professionals and volunteers in public health. Many students and professionals – mainly in medical professions – have opportunities to advance their knowledge in public health, for example, through summer schools and knowledge exchange with other countries in south-eastern Europe, EU-funded projects and WHO. Health professionals are subject to reaccreditation requirements for continuous training, for example, in public health. Partly, thanks to Slovenia’s close involvement in international programmes, which has narrowed distances in funding and expertise, the last decade has seen tremendous improvements in public health training for health professionals and others. In the absence of a national plan on the development of the public health workforce, no strategic goals for human-resources management have been defined. Professionals educated outside the health-related area are largely excluded from recruitment, accreditation, training, and career- development processes. As a result, their contributions are not well integrated into public health services. As is the case in the health sector in general, excellence and innovation are neither evaluated nor incentivized. Monitoring the performance of the public health workforce requires improvement. reliance on Eu funding and public tenders undermines the predictability and sustainability of funding. Public health education is not systematically aligned with international developments or the country’s needs. Professionals from outside the health sector have few opportunities to gain more public health knowledge and are not always aware of the possibilities that do exist. Competences in public health are not defined for medical specialists or non-health professionals, including those working in areas, such as health economics or e-health. Strengths Areas in need of further improvement Strengths Areas in need of further improvement 27 This section deals with the two essential aspects of the governance of human resources for public health: leadership and partnerships. Governance of human resources for public health The National Health Care Plan 2016–2025 (3) clearly prioritizes human- resources planning and management, representing an important opportunity for development in this area. In addition to the cadre of public health specialists, the Ministry of Health and NIJZ are actively coordinating public health programmes at the community level, in multisectoral collaboration with governmental and nongovernmental partners. This public health leadership, and the channels of cooperation it creates, represent a promising foundation on which to base the future governance of human resources for public health. Publicly funded activities run by NGOs are currently subject to little supervision or impact assessment. Professionals and volunteers working for NGOs would benefit from more training by, and direction from, public health institutions. Non-health sectors are usually little aware of their influence on public health. Existing educational institutions in Slovenia fall short in offering modern programmes with links to the international public health community and non-health disciplines. This has negative implications for attracting the best students from different backgrounds, and it weakens the capacity for leadership in public health education. Strengths Areas in need of further improvement © Ervin Matevžič 28 EPHO 8. Assuring sustainable organizational structures and financing See: EPHO 8 recommendations EPHO 8 deals with the appropriateness of the main organizational structures needed to carry out public health operations, the coordination mechanisms linking the operations, and the financing structures supporting their implementation. This section assesses the organizational structures of the Ministry of Health, NIJZ, the public health laboratory system, the quality-assurance mechanisms of community health centres, the enforcement agencies responsible for health-protection operations, the coordination mechanisms in place for services provided outside the government sector, and the oversight of all the above. Organizational structures and mechanisms The organizational structures for public health in Slovenia show a relatively good level of development. There are several strong institutions, led by the Ministry of Health, including two key public health institutions, NIJZ and NLZOH, with the political clout and technical capacity for public health leadership. The public health and health-care services are well integrated, and the National Health Care Plan 2016–2025 (3) has defined long-term goals for public health. The health-care system is well stratified, with clearly defined responsibilities and services, including preventive services. Despite being understaffed, laboratories are modern and well equipped. Although also subject to some staffing and funding limitations, the inspection system for the enforcement of public health legislation is generally adequate. The organization of public health services is hindered by the absence of a strategic vision and precise definitions of responsibilities. There is little coordination between, and/or integration of, the different services, for example, regarding the exchange of patient data between health-care institutions in the area of environmental health, and between laboratories (which function through competitive market- based schemes with no defined reference networks). Projects are often conceived with a short-term outlook and in reaction to shifting political priorities, and they are often implemented in isolation without reference to a unified set of national objectives for public health improvement. Established programmes are rarely subjected to systematic evaluation to determine whether activities require adjustment and, frequently, decisions are not evidence-based. Staffing shortages affect activities in several key areas, such as planning and governance, laboratories, inspection agencies and medical specialities. Enforcement agencies are challenged by fast-changing legislation and technological developments. Strengths Areas in need of further improvement 29 This section focuses on the budget needed to provide public health services in all areas, both within and outside government. It also examines the decision-making criteria used to allocate resources. financing public health services While routine funding decisions are typically made without the input of NIJZ, NLZOH or other public health organizations, there are several stable financing streams: ZZZS funds primary and secondary prevention and public health laboratory services (on a fee-for-service basis); the Ministry of Health funds NIJZ (€6.7 million allocated for the 2017 programme of work), other non-profit bodies (including the WHO Collaborating Centre for Health and Development in Murska Sobota), and high-tech hospital equipment; and the state budget funds enforcement agencies through different inspectorates. Decisions about resource allocation are slanted towards maintaining or increasing current levels of service provision, with an emphasis on increasing capacity for health-care services (for example, to reduce waiting lists). Decision-making has begun to be informed by the projected burden of disease and other health indicators, and demand is taken into account when planning new services. The Ministry of Health also actively engages international partners, including the European Commission and WHO, to secure support for a range of international projects. funds are insufficient to cover demand for public health services or pay health professionals competitive wages. Funding shortfalls are especially pronounced regarding implementation of the National Strategy on Databases, maintenance and expansion of critical infrastructures, recruitment of extra staff in peak periods, and continuous professional education in public health. funding streams lack the flexibility to adapt to changing circumstances. funding for public health services outside the health-system budget is very modest and limited to specific, time-bound programmes run by the Ministry of Agriculture, the Ministry of Education and MDDSZEM. There are practically no mechanisms for the stable intersectoral funding of services, and only weak cooperation with NGOs and other sectors. Decisions are made with little consideration of strategic long- term goals (including the roll-out of national health plans), cost- effectiveness analyses, budget-impact analyses, HTAs, and incentives for staff retention. financial limitations prevent the implementation of priority services planned at the national level, which are sometimes abandoned or postponed in favour of pursuing internationally funded projects. Some routine public health services, such as the performance of health surveys, lack a stable source of financing. Strengths Areas in need of further improvement 30 EPHO 9. Advocacy, communication and social mobilization for health See: EPHO 9 recommendations EPHO 9 assesses public health communication campaigns and the evidence-based integration of innovative information and communication technology (ICT) tools within communication and information programmes. This section deals with the planning, implementation and evaluation of health-communication programmes, including how the Ministry of Health fosters health communication, and how the programmes are organized, planned, implemented and evaluated. Strategic and systematic approach to public health communication The central role of health communication is widely acknowledged and formalized through public relations/communications offices in both the Ministry of Health and NIJZ; these offices have fluid relationships with the media and other target audiences. Likewise, institutional partners at the national, regional and local levels have open communication channels to discuss relevant topics, and local bodies are in good contact with their populations. Most public health programmes have their own strategies and communication plans; these have explicit objectives and are adapted to different mediums and audiences. In case of a crisis, the Government Communications Office effectively coordinates communication between government agencies to ensure the consistency and coherence of messages. Work is ongoing to systematize this through a new risk-communication strategy. Health communication activities are entirely unregulated, lacking national strategies for public health and health care, quality standards, and research, education and training guidelines. The organization of health-communication activities is generally ad hoc. Outside the area of crisis communication, there are no organigrams or formal channels of communication between different areas of the health sector or different programmes. The roles of the various professionals are not clearly articulated, and health-communication strategies are not connected. Campaigns are not based on in-depth analyses or piloted prior to roll- out, nor are they rigorously evaluated afterwards; thus, no data on their effectiveness are available. Communication is incompletely integrated into crisis management. No risk-communication simulation exercises take place, and health- care centres are ill-equipped to communicate about daily crises. financial and human-resources shortages impede the performance of planned activities. As a result, only 12 of the 93 public health-care institutions in Slovenia have professional communication support. Strengths Areas in need of further improvement 31 This section assesses whether ICT tools are being integrated in the health system in an evidence- based way. ICT for health There is growing recognition among decision-makers that modern information solutions have an important impact on the safety and quality of health care and that they have a vital role to play in supporting the health system as a whole. Individual e-health solutions, including electronic health records and e-prescriptions, have been implemented at the national level for the last three years and they represent important milestones in the informatization of the health- care system in Slovenia. The e-health project has been facing various challenges ever since its inception. These include: • management crises at the level of individual health-care providers; • failure to comply with legislation requiring the compulsory use of e-health solutions; • health-care providers’ lack of human and material resources in the field of ICT; • poor ICT infrastructure in the health-care system; • active action against the establishment and use of e-health solutions; • lack of consensus among health-care professionals regarding standards for clinical treatment. Tepid political and system support, and generalized shortages of resources (financial, human and organizational) have impeded the development and implementation of e-health applications. The uptake of e-health applications has grown in the recent period; however, it is still uneven in some areas. Strengths Areas in need of further improvement © Aleš Kolar 32 EPHO 10. Advancing public health research to inform policy and practice See: EPHO 10 recommendations EPHO 10 covers research, which is fundamental to informing policy development and service delivery. Research can be descriptive, analytical or experimental. It can be used to inform policy-making and political decisions, or to develop innovative solutions to public health problems. This section covers national processes for prioritizing research areas and their alignment with Health 2020: a European policy framework supporting action across government and society for health and well-being (5). This section assesses staff training and funding for strengthening public health research. Setting a national research agenda Capacity-building Decision-makers systematically use existing evidence and data to determine health-system priorities. There are also a few specific research initiatives on the socioeconomic determinants of health and community health, which are excellent models for future projects. The health-information system, combined with a good legal and ethical framework for data treatment, are the main strengths of the public health research system. There is generic support among health professionals for conducting research in their areas. The identification of public health research priorities is not strategic or integrated. Health-services research lacks development, which limits the capacity to gain an understanding of how well the system functions. The Slovenian research Agency does not formally recognize public health as an independent scientific discipline, which has important implications for funding public health. funding for public health research is unstable, which makes it difficult to monitor programmes and long-term outcomes on a continuous basis. research activities are rarely integrated into public health workforce training or practice, and there are few collaborative agreements between, or networks involving, the research community and the workforce. Gaps in the health-information system (for example, lack of national registries for NCDs) result in low capacity for, and prioritization of, research into major public health problems. The workforce has no contractual obligations, career-advancement incentives, or practical opportunities to conduct research or develop innovative solutions to public health challenges. Strengths Areas in need of further improvement Strengths Areas in need of further improvement 33 This section assesses the measure of understanding in the country regarding research currently taking place, and how the Ministry of Health can shape the research agenda of other stakeholders through collaboration and partnerships and the provision of clear guidance on national priorities. This section deals with the extent to which research evidence is applied to policy and practice. Coordination of research activities Dissemination and knowledge brokering The Slovenian Research Agency supports research projects and programmes, as well as multidisciplinary partnerships with health- research centres and academic institutions. It also uses a software programme (of the Slovenian Current Research Information System) to monitor and coordinate research organizations and research projects. Recent years have seen a tightening of the ties between the research and policy communities, with increasing emphasis on generating policy-friendly research products, guidelines and recommendations. Projects of the country’s targeted research programmes represent an important mechanism to this end. The research community’s involvement in health-policy planning and the development of indicators are especially pronounced in the fields of cancer and diabetes. At the same time, programme strategies are routinely laid out in white papers and other key policy documents, also in cooperation with international organizations, such as WHO. The recently founded journal, “Public Health” (15), published by NIJZ, is another channel for communicating evidence. The inadequate formal definition of public health research is undermining the development of a strategic vision in this field. There is no formally coordinated national research network in public health, which can lead to duplication and lack of project integration. Not all stakeholders adhere to the National Strategy for Open Access to Scientific Publications and research Data in Slovenia 2015–2020 (16), which limits the dissemination and application of results. Programme evaluation is inadequate, making it impossible to gain an understanding of the effectiveness of services in meeting their objectives. Strengths Areas in need of further improvement Strengths Areas in need of further improvement © Drazen Stojanovic 35 POlICy rECOMMENDATIONS EPHO 1 See: Key findings for EPHO 1. Three priority areas were identified: 1. improvement of existing data sources and dissemination methods 2. modernization of the data-collection system 3. collection of data on patient experiences. GOAl. To improve the quality and completeness of the existing sources of health data and expand the tools for reporting health data and disseminating health indicators. EffOrT: 3/5 IMPACT: 5/5 r1.1. Improve existing sources of health data and expand tools for the dissemination of health indicators PrOPOSED ACTION Ministry of Health (in close consultation with NIJZ and other professional bodies maintaining national health data sources) • Introduce appropriate national legislation and ensure the stable financing of health registries and databases, as well as health- related surveys and corresponding information systems. • Ensure health-care providers report regularly on health indicators to identified key groups. • Define health registries and health-related surveys essential to national health statistics, based on predefined eligibility criteria. Specific databases proposed for other EPHOs include: – environmental factors and health outcomes – registry of occupational diseases – database of all information needed for food-safety risk assessment – information system for sentinel and other adverse health events; – registry of malpractice suits. The following recommendations (R.1–R.10) are specific, actionable points that the Government of Slovenia, working primarily through the Ministry of Health and NIJZ, could consider during the development of a national strategy for public health services. While they are organized around the different EPHOs, each measure proposed represents a synthesis of the contributions made by the EPHO Specialized Teams. The implementation of any of them will inevitably have an impact across different areas of the health system. 36 GOAl. To unify the data-collection system in health care and to ensure the collection of data needed for the purposes of relevant health-system stakeholders (Ministry of Health, NIJZ, ZZZS). GOAl. To better understand the patient experience in the Slovenian health-care system and to gain an insight into health services from the patient’s point of view. EffOrT: 5/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 4/5 r1.2. rationalize, standardize and modernize the data-collection system in health care r1.3. Gather information on the health-care system from the patient perspective PrOPOSED ACTION PrOPOSED ACTION NIJZ • Propose the assessment, revision and renovation of the existing data-collection system in health care and lead the process. • Lead the renovation of the outpatient system, in close cooperation with ZZZS and health-care providers who would be required to submit data on a monthly basis. • Together with the Ministry of Health, invest in the development of human capacity for planning and implementing a system of data collection and analysis. Ministry of Health • Assess and revise existing legislation on the collection of health- care data (Health Care and Health Insurance Act, Health Care Databases Act). • Establish a working group to direct the unification of the data- collection and dissemination systems in health care. • Mobilize the financial resources necessary to enable the renovation of the data-collection system. • Together with NIJZ, invest in the development of human capacity for planning and implementing the data-collection and analysis system. Ministry of Health (in close cooperation with NIJZ and other professional bodies) • Intensify work on PROMs and PREMs by mobilizing the human and financial resources necessary to establish a patient-centred information system. 37 EPHO 2 See: Key findings for EPHO 2. While many components of Slovenia’s systems of emergency preparedness and response work well, they do not always work together. Thus, the following recommendations relate to the need for a central body to coordinate the action of the different agencies and stakeholders involved, through a unified plan based on an all-hazards/one-health approach. Special attention would need to be paid to shoring up human and financial resources. GOAl. To enable the centralized coordination of health-sector and other stakeholder emergency- preparedness capacities, through a holistic and collaborative approach. GOAl. To unify national security and public health preparedness in a single plan, including: • a list of hazards relevant to Slovenia, along with priorities for action; • coordinated public health emergency-response plans at the national, regional and local levels, which clearly define the roles of all participating institutions (Ministry of Health, NIJZ, URSZR, etc.); • improved and developed guidelines, factsheets, and background materials, defining the roles and functions of the emergency-operations centres, to ensure the continuity and traceability of operations; • common IT standards across all institutions in the system; • recognition of risk communication as a core element in the planning and management of emergency preparedness and response. EffOrT: 2/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 5/5 r2.1. Establish a permanent emergency response unit in the Ministry of Health r2.2. Develop a health-sector emergency plan PrOPOSED ACTION PrOPOSED ACTION Ministry of Health • Create and staff a permanent, full-time emergency-response unit responsible for planning and developing health security and for (among others): – collaborating with other sectors across government on multisectoral policies and plans that complement the National Civil Protection Strategy; – integrating risk communication as a core element in crisis preparedness and response. Ministry of Health (with the professional support of NIJZ and NLZOH) • Develop a national plan for all-hazards public health emergency preparedness and response to complement and coordinate existing plans for different emergency possibilities. • Transform individual plans into SOPs that are cohesive and consistent across all ministries, including guidance on response to unique situations. 38 GOAl. To prepare Slovenia’s workforce for response to the next public health emergency. EffOrT: 3/5 IMPACT: 5/5 r2.3. Implement regular training in emergency preparedness and response through simulation exercises PrOPOSED ACTION Ministry of Health • Develop a common plan of periodic public health emergency training and realistic simulation exercises to improve multisectoral preparedness and response. • Formulate a specific strategy for identifying and integrating lessons learned in different plans and procedures. • Periodically convene meetings with all involved partners to update them on new developments in their respective areas, ensure continuity of education, and conduct collaborative exercises. © Gasper Stopar 39 EPHO 3 See: Key findings for EPHO 3. The comprehensive self-assessment of Slovenia’s health-protection activities showed the presence of a robust regulatory framework in most areas. Environmental health, occupational health, and patient safety, however, all require comprehensive strategies that establish intersectoral capacities for health protection. Other gaps should be filled through more targeted legislation. GOAl. To protect human health from environmental threats through intersectoral cooperation. EffOrT: 3/5 IMPACT: 5/5 r3.1. Design a comprehensive strategic environmental health plan and strengthen Ministry of Health, NIPH and NlzOH capacities for environmental health PrOPOSED ACTION Ministry of Health • Establish a new department for environmental health in the Public Health Directorate. • Conduct a situation analysis of environment-related public health problems. • Coordinate a participatory process, involving NIJZ, NLZOH and others, to develop a strategic environmental health plan. GOAl. To fill regulatory gaps in areas with little environmental health protection. EffOrT: 4/5 IMPACT: 4/5 r3.2. Strengthen legislation on environmental protection and its enforcement PrOPOSED ACTION Ministry of Health (together with the Ministry of the Environment and Spatial Planning, the Ministry of Economic Development and Technology, the Ministry of Infrastructure, NLZOH and NIJZ) • Conduct a situation analysis of regulatory and enforcement activities related to soil contamination, remediation of excessively polluted areas, and quality of ambient and indoor air, noise, odour and asbestos. • Develop legislation to fill needs gaps and align inspection capacity to enforce regulations. • Propose and implement systemic changes, including the conduct of compulsory HIAs. • Consider introducing incentive mechanisms to encourage private stakeholders to protect environmental health, for example, state subsidies to promote the proper handling of asbestos materials and disposal of asbestos waste. 40 GOAl. To achieve the systematic regulation of quality and safety in health care. GOAl. To address limitations in the current occupational medicine system, particularly the registry of occupational diseases, and cooperation between MDDSZEM and the Ministry of Health. EffOrT: 4/5 IMPACT: 4/5 EffOrT: 3/5 IMPACT: 4/5 r3.4. Accelerate and renew regulatory and implementation activities for patient safety and the quality of health care r3.3. Improve accountability for the organization and delivery of occupational medicine PrOPOSED ACTION PrOPOSED ACTION Ministry of Health and key stakeholders (ZZZS, NIJZ, Association of Health Institutes of Slovenia, Medical Chamber of Slovenia, Nurses and Midwives Association of Slovenia, NGO 25x25) • Prepare and implement an act on quality and safety in health care. • Implement measures foreseen in the National Health Care Plan 2016–2025 (3) in relation to the field of communication and development of integrated health care, the government project on patient safety, and projects supported by the EU Structural Reform Support Service. • Introduce rules on the distribution of commercial products in all community health centres, banning the distribution of materials, such as promotional packages for neonates and advertising leaflets, promoting pharmaceuticals or dietary supplements. Ministry of Health • Analyse the current occupational health system and propose specific measures for its renovation. • Build human-resources capacity in occupational health protection. • Implement more and better health-promotion activities in the workplace. MDDSZEM and Ministry of Health • Collaborate on updating occupational health legislation to include: – new rules defining occupational diseases; – enhanced family-leave protection. 41 GOAl. To expand consumer protection to the area of online sales. EffOrT: 5/5 IMPACT: 3/5 r3.5. Ensure the safety of online sales PrOPOSED ACTION The Inspection Council and the Inspectorates, all ministries and their bodies (in cooperation with EU, NIJZ and NLZOH) • Review the status of legislation regulating online sales. • Propose legislative amendments to ensure the safety of food and other products sold online. • Engage in international cooperation to develop a method of ensuring the safety of products sold online. NIJZ • Design and implement awareness campaigns to draw the attention of the general public to risks of online purchasing. GOAl. To develop spatial planning guidelines to which planners can refer when integrating health protection into planning activities. EffOrT: 3/5 IMPACT: 4/5 r3.6. Strengthen intersectoral accountability for human health through guidelines for spatial planning PrOPOSED ACTION Ministry of Health (in collaboration with the stakeholders envisaged in the Spatial Planning Act (17)) • Take the lead in setting up an intersectoral project to develop comprehensive spatial planning guidelines, incorporating considerations for the protection of human health. © NIJZ 42 EPHO 4 See: Key findings for EPHO 4. While there are good health-promotion programmes in some areas, others are relatively undeveloped. Moreover, there is a need to strengthen collaboration networks and mechanisms for intersectoral work from the national to the local level, and between public and nongovernmental and private actors. GOAl. To create a specific channel through which to realize a HiAP approach at the government level. GOAl. To strengthen bilateral and multilateral collaboration on specific public health issues. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 2/5 IMPACT: 4/5 r4.1. Create a high-level interministerial working group on population health r4.2. Create cross-cutting technical working groups for priority health topics, including representatives of NGOs and the private sector, when appropriate PrOPOSED ACTION PrOPOSED ACTION National Council for Health (with the support of the Ministry of Health) (see R8.7) • Create an interministerial working group on health to: – conduct systematic HIAs and health-equity audits of new legislation; – propose amendments to existing legislation to integrate health- promotion and health-equity concepts (for example, safety, nutrition, physical activity), in line with national strategies and priorities; – host interministerial policy dialogues, expert events, and communication campaigns on various health topics, including health inequalities. Ministry of Health, National Council for Health, NIJZ, and other relevant actors • Establish or restore cross-cutting bodies in the following areas: • mental health • alcohol • injury prevention and safety • health promotion/education in schools • rehabilitation services • spatial planning • environmental health • violence • nutrition and physical activity • iodine • tobacco • prison health • vulnerable populations. 43 GOAl: To empower municipalities and regional development agencies to promote population health at the local level. EffOrT: 3/5 IMPACT: 5/5 r4.3. Strengthen the public health mandate and public health capacity in regions and municipalities PrOPOSED ACTION Local self-government services of the Ministry of Public Administration (in collaboration with the Ministry of Health) • Include health protection and promotion as priority content of regional development agencies, with an emphasis on small municipalities. Ministry of Health, all Slovenian municipalities • Contribute jointly to financing regional NIJZ units (each municipality contributing to its own regional unit) that design and implement health-promotion programmes tailored to local needs and national priorities. Regional NIJZ units • Collaborate with local authorities, health centres, social services, NGOs and other local stakeholders to promote a community approach to addressing the health determinants, with an emphasis on vulnerable groups. Joint action plans should provide explicit practical guidance on: – identifying regional public health priorities; – raising awareness about health and relating it to all aspects of community life; – familiarizing community stakeholders with national strategies (such as the National Programme on Nutrition and Physical Activity for Health) and the roles and opportunities, rights and obligations of the local community; – implementing national health-promoting programmes, as well as promotional campaigns and activities in different settings and populations, tailored to specific needs in the region; – promoting and strengthening mental-health services, including their transfer to the community level, and developing a community approach to substance abuse and addiction. 44 GOAl. To create controlled policy spaces, enabling the pursuit of strategic partnerships and collaboration with the private sector. EffOrT: 2/5 IMPACT: 4/5 r4.4. Manage structures and processes for public–private collaboration PrOPOSED ACTION Ministry of Health • Adopt a single protocol for the establishment and functioning of public–private partnerships, in accordance with WHO guidance. • Invite private stakeholders to participate in the preparation of strategic documents. GOAl. To align public health legislation with international recommendations and evidence. EffOrT: 3/5 IMPACT: 5/5 r4.5. Prepare a public health legislation package for tackling the main behavioural, environmental and social determinants of health PrOPOSED ACTION Ministry of Health (with technical support from NIJZ and in cooperation with other sectors) • Draft new regulations in the following areas: – tobacco (to include: tax increases on all products, minimizing price differences between products; new restrictions on the eligibility, number and density of points of sale; restrictions on marketing in digital media); – alcohol (to include: licensing system for alcohol sales; restrictions on the eligibility, number and density of points of sale, and on consumption; marketing bans; periodic tax increases; requirement of 0.0 g alcohol/kg blood in all drivers); – injury prevention and sexual health (to amend rules related to implementing health promotion, for example, in primary health care and schools); – nutrition (to include: front-of-package food labelling; marketing of breastmilk substitutes and complementary foods; quality assurance in the public procurement system; marketing that targets children); – mental health (to regulate psychological and psychotherapeutic activity by introducing relevant legislation, including the remits of professionals working in these areas). PrOPOSED ACTION Ministry of Health (in cooperation with other sectors, NIPH and other relevant stakeholders) • Prepare, update, adopt and/or implement relevant strategic documents (strategies, action plans) in different areas. These should encompass (but not be limited to): – mental health (priority measures to be implemented through the National Programme on Mental Health 2018–2028 (13), such as: community- and primary-care-based approaches; the systemic introduction of effective mental-health promotion; programmes on the prevention of mental disorders and anti- stigma programmes; programmes targeting the intersection between alcohol abuse and mental health; suicide-prevention measures; and surveillance and evaluation related to research and programmes on risk factors); – alcohol (creation of a coordinating body; interventions in community health centres; advocacy for comprehensive control policies; surveillance of alcohol production and consumption; server training and community service for minors caught purchasing alcohol); – tobacco (health-promotion campaigns and enforcement of the Restriction on the Use of Tobacco and Related Products Act); – sexual and reproductive health (increasing access to services and defining rules for the delivery of health-promotion and disease-prevention services); – family violence prevention (collaboration with all relevant stakeholders, including MDDSZEM, the Ministry for Education, Science and Sports, NGOs, etc., to introduce the protection of survivors, especially vulnerable populations, such as pregnant women and children). Each document should include specific provisions targeting underserved or vulnerable populations (children, adolescents, pregnant women and new families, elderly people, migrants, Roma communities, people with low socioeconomic status, etc.). 45 GOAl. To consolidate the positions and priorities of the health system in core areas affecting population health, with a special focus on health equity. EffOrT: 3/5 IMPACT: 5/5 r4.6. Prepare strategic documents setting out national priorities and programme planning 46 EPHO 5 See: Key findings for EPHO 5. Disease-prevention activities require updated legislation to optimize vaccination rates, extend access to preventive services to high-risk populations, and help patients and their families manage processes related to long-term disease, dependency, rehabilitation, and death. Slovenia could also take specific measures to ensure that vulnerable populations, including people in prisons, have access to these services. GOAl. To realize the objectives laid out in the National Health Care Plan 2016–2025 (3) to expand access to primary health care and outreach programmes to vulnerable populations. GOAl. To achieve sufficient vaccination coverage to protect the population from communicable diseases. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 2/5 IMPACT: 4/5 r5.1. Adopt a national strategy for the development of primary health care r5.2. Amend the Communicable Diseases Act PrOPOSED ACTION PrOPOSED ACTION Ministry of Health, NIJZ, ZZZS • Develop and adopt a national strategy for the development of primary health care aimed at: – designing systems for detecting vulnerability among certain groups, in cooperation with relevant stakeholders at the national level; – introducing the International Classification of Functioning, Disability and Health (18) in Slovenia; – defining cooperation between public health and primary-care services with a view to encouraging vulnerable populations to use health services; – updating the rules on the provision of preventive health care at the primary level, aligning them with population needs and state-of-the-art practice to, among others: • allow pregnant women to access chromosomopathy screening free of charge; • extend cancer screening to populations without compulsory insurance. Ministry of Health (in cooperation with NIJZ) • Draft a legislative amendment of the mandatory vaccination procedures, which will contribute to maintaining and improving the immunization rate. 47 GOAl. To improve prison health through specific, targeted measures that complement and unify existing services. GOAl. To fill the gaps in the access of different people to rehabilitation services, and to facilitate caregivers’ work. GOAl. To ensure that activities in palliative care are rolled out as planned. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 3/5 IMPACT: 3/5 EffOrT: 3/5 IMPACT: 3/5 r5.3. Implement key measures in prison health services r5.4. Organize rehabilitation services at all levels of health and social care r5.5. Support the implementation of planned activities in palliative care PrOPOSED ACTION PrOPOSED ACTION PrOPOSED ACTION Ministry of Health (in collaboration with NIJZ and Ministry of Justice) • Organize regular meetings among health professionals working in prisons to develop joint approaches to resolving problems in a coordinated way. • Grant all prisoners vaccinations against hepatitis A and B free of charge. • Introduce peer-to-peer programmes, focusing on disease prevention. Ministry of Health and its consultation bodies • Prepare a protocol for the comprehensive treatment of patients in rehabilitation procedures at all levels and in all fields (primary and secondary health care; social and occupational services). • Prepare clinical guidelines on patient pathways between primary and secondary health-care levels. Ministry of Health • Advocate, through public discussion, the implementation of the National Programme for Palliative Care and operations of the Expanded Professional Board for Palliative Care. • Recommend the Health Insurance Institute to finance the already appointed regional coordinators of palliative care. Ministry of Health and municipalities • Design schemes to support home care. 48 GOAl. To increase the transparency of the operations of patient associations and the flow of information between them, and determine good practice in the management of funds dedicated to patient groups, as well as future funding needs. GOAl. To define quality standards for, and ensure equal access to, long-term care services, as well as the protection of caregiver rights. EffOrT: 4/5 IMPACT: 2/5 EffOrT: 3/5 IMPACT: 4/5 r5.6. Assess the organization, ground rules and activities of patient associations r5.7. Adopt the long-term Care Act PrOPOSED ACTION PrOPOSED ACTION NIJZ • Conduct an analysis of patient groups in Slovenia, drawing up an inventory of involved organizations, including content, scope of activities, number of members, etc. • Use the results of the analysis to draft proposed priorities and measures. Ministry of Health and MDDSZEM • Work towards the prompt adoption of legislation on long-term care. © Gasper Stopar EPHO 6 See: Key findings for EPHO 6. The National Health Care Plan 2016–2025 (3) envisages the adoption of a national strategy for the development of the public health system, based on the results of the EPHO self-assessment. This project reflects the tremendous positive momentum that exists for strengthening public health governance in Slovenia and represents a unique opportunity to generate system-wide consensus for the direction that public health should take in the country. Specific mechanisms related to governance – apart from the adoption of a public health development strategy – relate to the creation and use of evidence in policy-making, including that in the areas of HTA and quality standards for public health services. GOAl. To use the results of the EPHO self-assessment to set the direction for the development of public health services in Slovenia. GOAl. To strengthen evidence-based decision-making on new treatments and medical technology. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 5/5 IMPACT: 5/5 r6.1. formulate a national strategy for the development of the public health system, as foreseen in the National Health Care Plan 2016–2025 r6.2. Create an independent agency for health technology assessment PrOPOSED ACTION PrOPOSED ACTION Ministry of Health, NIJZ and NLZOH • Consider the results of the present self-assessment. • Hold a policy dialogue with all key experts to identify ways of operationalizing the recommendations identified in the self- assessment on developing public health capacities and services. • Draft a national public health strategy, ensuring synergies with key stakeholders, especially primary health care providers and non-health sectors, and work with government to finance its implementation. Ministry of Health, NIJZ and NLZOH • Mobilize financial and human resources to create a HTA agency. • Develop the governance mechanisms and objectives needed to carry out the agency’s mission, in alignment with the rest of the health system. 49 50 GOAl. To establish and promote clear standards and evaluation criteria for public health services. GOAl. To strengthen accountability in the delivery of public health services and keep policy-makers informed of population-health needs. EffOrT: 5/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 5/5 r6.3. Define and promote quality standards for public health services r6.4. Prepare biennial reports on population health for the Parliament PrOPOSED ACTION PrOPOSED ACTION NIJZ, NLZOH and universities • Establish a specific platform for the preparation and adoption of national guidelines, including standards and quality indicators in the field of public health. • Develop mechanisms for the identification and exchange of good practice (including that related to services delivered by NGOs). NIJZ • Issue biennial reports on population health to the Parliament, covering: – key indicators of the health status of the population – status of the implementation of planned activities – impact of ongoing activities and recommendations on adjustments. © Sabina Petronio 51 EPHO 7 See: Key findings for EPHO 7. The findings of the present self-assessment highlight the acute need for the centralized planning, generation, and management of human resources for public health. The lack of formal leadership in this area undercuts Slovenia’s capacity to deliver core public health services. GOAl. To ensure alignment between the supply of and demand for different professionals in the field of public health and to build and sustain human-resources capacity for public health services. EffOrT: 5/5 IMPACT: 5/5 r7.1. Establish a coordinated process for planning and monitoring the public health workforce through a national strategic human- resources plan PrOPOSED ACTION Ministry of Health • Designate a specific body to coordinate public health workforce planning, which would, in cooperation with the Ministry of Health, NIJZ, ZZZS, universities, and professional chambers and associations: – perform a needs assessment of current and future demand for public health professionals, including those working outside the medical field (for example, inspection agencies); – work to increase the person-time dedicated to public health services throughout the health system; areas with urgent human-resources needs include: • emergency preparedness and response (especially risk assessment, toxicology and ecotoxicology) • health communication • substance-abuse programmes • mental-health programmes; • palliative care and home care • quality assurance • research, especially health- services research • planning and governance activities • public health inspection and enforcement agencies • laboratory system • occupational health • primary- and secondary-level health centres • safety promotion • rehabilitation services. • Develop and adopt a national human-resources plan that would cover the public health workforce, incorporating measures to ensure workforce sustainability, such as teaching opportunities for expert professionals. • Mobilize resources to financially support the workforce strategy and assign personnel in formalizing cooperation between public health institutions. NIJZ • Set up a tender system for students applying for different health programmes. 52 GOAl. To expand opportunities for non-medical professionals in public health and create a critical mass of public health experts in different public health disciplines. GOAl. To ensure that professionals’ knowledge and competences grow in tandem with advances in the field of public health. EffOrT: 5/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 5/5 r7.2. Create a national school of public health r7.3. Align workforce knowledge and skills with the current state of the art PrOPOSED ACTION PrOPOSED ACTION Ministry of Health, NIJZ, national and international teaching institutions • Secure the resources and infrastructure needed to set up a national school of public health. • Engage with the Association of Schools of Public Health of the European Region, and through it, formalize relationships with other schools of public health. • Design modern public health degree programmes, including a master’s programme open to non-health professionals and a focus on research activity. Government of Slovenia, Ministry of Health • Generate funding for the continuous training of public health professionals working both within (for example, in primary health care) and outside the health-care sector (for example, in education). • Organize continuous training programmes for public health professionals, including study abroad. NIJZ (in cooperation with providers of public health study programmes) • Define and periodically update the standards of knowledge and skills required for each class of public health professional. • Design and implement continuous training programmes (for example, summer schools, workshops) to update professional competences. Curricula should include knowledge translation and policy analysis and evaluation, among other concepts. • Systematically integrate research activities into public health training and practice. • Open managerial training courses organized for staff in the public administration to managers in public health. 53 GOAl. To build the capacities of key professionals in accurate communication and evidence-based decision-making relating to public health. EffOrT: 1/5 IMPACT: 5/5 r7.4. Design training opportunities aimed at providing an understanding of public health evidence, targeted to politicians, journalists, and managers in the health and other sectors PrOPOSED ACTION NIJZ • Design and implement training courses, seminars, workshops and other learning events on public health evidence for decision-makers and media workers. © Foto Molan 54 EPHO 8 See: Key findings for EPHO 8. The self-assessment highlighted specific areas where organizational structures and decision-making processes hinder the effective implementation of national public health priorities and programmes. Funding shortages are a general problem, but they are especially acute for national laboratories, the health-information system, NIJZ programming, and intersectoral activities. GOAl. To create pathways of accountability in Slovenian public health institutions, based on strategic institutional goals and processes. GOAl. To enable Ministry of Health directorates to allocate finances for public health activities in accordance with the strategic goals defined in national, legal and planning documents. GOAl. To ensure that health policies and decisions on resources allocation are based on population needs and scientific evidence. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 5/5 IMPACT: 5/5 EffOrT: 3/5 IMPACT: 5/5 r8.1. revise the organization of the Ministry of Health and NIJz to make it more process-oriented and aligned with the regulatory framework r8.2. Introduce a strict budget for population-based prevention r8.3. Strengthen evidence-based planning, prioritization, financing and implementation of public health activities and legislation PrOPOSED ACTION PrOPOSED ACTION PrOPOSED ACTION Ministry of Health (in collaboration with NIJZ) • Revise the institutional organigrams of the Ministry of Health and NIJZ, based on legal documents and strategic plans (Regulation on Preventive Activities, Resolution on the National Plan, national programmes, etc.), ensuring a clear definition of responsibilities. Ministry of Health, Ministry of Finance, Health Insurance Institute • Negotiate budget arrangements to ensure explicit, sustained funding for population-based prevention services. Ministry of Health, NIJZ, NLZOH and other relevant health partners • Standardize phases of the policy-making cycle, introducing explicit consideration of short- and long-term goals, cost-effectiveness analyses, budget-impact analyses, HTAs and outcomes analyses. • Revise the tender system for NGOs, the core activity of which is health promotion and disease prevention, and allocate resources based on defined criteria (competences and capacities). 55 GOAl. To afford NIJZ financing structures more stability and autonomy. GOAl. To improve links and the division of labour between laboratories for better efficiency. GOAl. To fill the supply–demand gap related to public health laboratories. EffOrT: 4/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 5/5 EffOrT: 3/5 IMPACT: 5/5 r8.4. Introduce a stable, secure budget line for regular public health programmes run by NIJz, independent of funds allocated for specific, short-term projects r8.5. Establish national laboratory networks, including reference laboratories r8.6. Allocate additional financial resources for public health laboratory functions PrOPOSED ACTION PrOPOSED ACTION PrOPOSED ACTION Ministry of Health, Ministry of Finance • Mobilize new funding streams and earmark funds to finance stable NIJZ programmes, in line with national goals. Ministry of Health, NLZOH, Institute of Microbiology • Implement action laid out in the National Health Care Plan 2016–2025 (3) to establish laboratory networks and reference laboratories in key areas. • Establish a systematic process of prioritizing and performing public health laboratory activities, in cooperation with all partners. Ministry of Health, NLZOH, Institute of Microbiology • Prepare a detailed needs assessment for public health laboratories, including human resources. Ministry of Health, Ministry of Finance, Health Insurance Institute • Scale up funding of the laboratory system. 56 GOAl.To assure the funding and organization of intersectoral activities for health. EffOrT: 4/5 IMPACT: 5/5 r8.7. Secure the proper organization and financing of complementary public health services outside the remit of institutional public health PrOPOSED ACTION Government • Redefine the mission of the National Council for Health to include its taking over the governance and coordination of all health- related intersectoral activities at the national and regional levels. Ministry of Health, National Council for Health • Mobilize intersectoral mechanisms to fund and organize public health services outside the health sector, for example, population- based registries. © NIJZ 57 EPHO 9 See: Key findings for EPHO 9. While the importance of health communication is generally recognized, communication activities are still carried out on an ad hoc basis with few staff members and limited capacity for evaluation. A national strategy for health communication, combined with an articulated set of awareness campaigns across media, is needed to effectively engage the population in matters of public health. Moreover, it is necessary to fully implement e-health solutions in order to modernize the delivery and coordination of health-care services. GOAl. To include communication in all phases of planning and implementing Ministry of Health activities in the field of public health. GOAl. To establish and maintain a good level of public awareness on key issues that affect human health and to combat misinformation from untrustworthy sources. EffOrT: 5/5 IMPACT: 5/5 EffOrT: 2/5 IMPACT: 5/5 r9.1. Develop a national strategy for health communication r9.2. regularly implement awareness campaigns to educate the general public and professionals in non-health sectors on public health matters PrOPOSED ACTION PrOPOSED ACTION Ministry of Health, NIJZ, Association of Health Institutes of Slovenia • Prepare a national communication strategy that establishes: – standards for communication in the health-care sector; – standards for communication between the health sector and competent profiles in institutions covering the field of public health; – goals, including targets for health literacy in the population, as well as roles and tasks; – processes for developing communication campaigns (from planning and piloting to evaluation); – links at the vertical (international, national, regional, local) and horizontal (interinstitutional) levels. NIJZ, in cooperation with the Ministry of Health and other stakeholders (health professionals, NGOs) • In alignment with the processes established in the national strategy on health communication, design and/or adapt health- communication materials for regular and ongoing media campaigns (TV, radio, print) and target audiences (young people, elderly people, vulnerable communities, etc.) in various areas, including: • injury prevention and safety promotion • mental health • violence • nutrition and physical activity; tobacco, including new products • non-chemical addiction • awareness raising (health days and other events) • vaccination. 58 GOAl. To increase the quality of health-care delivery, promote patient empowerment and safety, and ensure the more efficient management and operation of the health-care system through digitalization. EffOrT: 5/5 IMPACT: 5/5 r9.3. foster the national implementation of e-health solutions PrOPOSED ACTION Ministry of Health, in close cooperation with NIJZ, ZZZS, and patient and professional associations • Prepare advocacy tools, including policy briefs and financial justification of the cost benefits of ICT. • Mobilize funding for the implementation and use of e-health solutions. • Educate medical and public heath professionals about, and raise awareness of, the potential benefits of e-health. • Lease web domains in different public health areas and maintain a presence in the social media to combat unverified rumours and erroneous health information. © Gašper Stopar 59 EPHO 10 See: Key findings for EPHO 10. While Slovenia is active in public health research, there is still a need to establish public health as a research discipline in its own right, and in turn set up mechanisms of prioritizing and coordinating activities. Although Slovenia should continue to make the most of research opportunities offered through international collaboration, the country should also invest in national priorities, especially health-services research. Access to and use of the findings of such research would be served by the generation of advocacy tools and policy-making aids, as well as the open-access dissemination of research products. GOAl. To reclassify the field of public health in accordance with up-to-date national and international definitions of the field. GOAl. To ensure Slovenia’s capacity to determine whether public health policies and programmes are meeting their stated objectives. EffOrT: 2/5 IMPACT: 5/5 EffOrT: 5/5 IMPACT: 4/5 r10.1. Establish public health as an independent research field in the national classification system of the Slovenian research Agency r10.2. Establish a monitoring system to evaluate public health policies and programmes, including those delivered outside the public sector PrOPOSED ACTION PrOPOSED ACTION National research community, key stakeholders in the field of public health (Ministry of Health, NIJZ, academic researchers, scientific societies) • Prepare a joint expert statement, supporting the reclassification of the field of public health currently entitled “Public Health Care Systems – Occupational Safety”, and proposing that its title be changed to “Public Health”, and submit it to the Slovenian Research Agency for formal consideration. Slovenian Research Agency • Consider the above statement and the reasons for submitting it, propose amendments as required, and introduce the changes. Ministry of Health • When considering the viability of programme proposals, include as a criterion, the presence in plans and budgets of basic evaluation models and systematic monitoring, also with respect to efficiency and cost-effectiveness. NIJZ, NLZOH and universities • Apply the principles of HTA to determine the impact and outcomes of programmes implemented by NGOs and other civil-society actors. 60 GOAl. To create the means for developing coherent public health research priorities and generating evidence in formats accessible and useful to decision-makers and the public. GOAl. To take advantage of opportunities for funding, knowledge translation and networking at the international level. This would strengthen national health research and policy, as well as the European Research Area. GOAl. Ultimately, to persuade policy-makers of the need to advance a whole-of-government approach to public health. EffOrT: 2/5 IMPACT: 5/5 EffOrT: 4/5 IMPACT: 4/5 EffOrT: 3/5 IMPACT: 4/5 r10.3. Develop a platform for coordinating and disseminating public health research r10.4. Invest in advocacy tools to facilitate the advancement of public health policies and programmes r10.5. Scale up Slovenia’s involvement in international and European activities in the field of health PrOPOSED ACTION PrOPOSED ACTION PrOPOSED ACTION NIJZ and representatives of national public research organizations, in cooperation with the Ministry of Heath and the Ministry of Education, Science and Sport • Organize a public consultation process to identify national public health research priorities. • Develop consensus-based criteria for prioritizing and agreeing on research objectives, resources and capacities across the various fields of public health. NIJZ • Prepare policy briefs and other decision-making aids for communication with policy-makers on public health policy. • Periodically prepare comprehensive assessments of the impact of socioeconomic risk factors on health. Ministry of Health • Form a working group or internal committee, including representatives of the Ministry of Health, the Ministry of Education, Science and Sport, national health-research programmes, and the Scientific and Research Council in the field of medicine of the Slovenian Research Agency. • Mandate the working group to take decisions regarding Slovenia’s participation in international and European initiatives, and on national commitments of human and financial resources. 61 GOAl. To ensure access to research data on health and health-care research and their use in informing policy on health care and public health. EffOrT: 3/5 IMPACT: 4/5 r10.6. Strengthen implementation of the National Strategy for Open Access to Scientific Publications and research Data in Slovenia 2015–2020 PrOPOSED ACTION Ministry of Health, Slovenian Research Agency • Identify measures to support the implementation of the National Strategy for Open Access to Scientific Publications and Research Data in Slovenia 2015–2020 (to be taken by all stakeholders). • Mobilize funding for the publication of research data in formats targeted to the research community and policy-makers. © NIJZ © Dražen Stojanović 63 The EPHO self-assessment in Slovenia provided the opportunity to evaluate the status of public health services across the country and determine the priorities for public health development. It illustrated the strengths and capacities of the services, as well as their organizational, resource and workforce implications, and revealed areas in need of development and action. The process was carefully designed to be coordinated, managed, and carried out by national professionals, with the close support of WHO experts and the engagement of representatives from all key public health and partnering ministries and institutions. An additional value of the self-assessment process is its contribution to building national capacities, strengthening networking and teamwork, and developing a shared understanding of public health as a system. The roles, functions, and tasks of each key partner in the national network of the public health system were also discussed and clarified during the process. The recommendations resulting from the process will eventually contribute to the development of a national public health strategy and to strengthening the HiAP/whole-of-government approach. It will also promote implementation of the 2030 Agenda for Sustainable Development (19) and the Global Action Plan for Healthy Lives and Well-Being for All (20) with the aim of improving population health and reducing health inequalities. CONCluSIONS 64 rEfErENCES1 1. European Action Plan for Strengthening Public Health Capacities and Services. Copenhagen: WHO Regional Office for Europe; 2012 (https://www.euro.who.int/__data/assets/pdf_ file/0005/171770/RC62wd12rev1-Eng.pdf). 2. Self-assessment tool for the evaluation of essential public health operations in the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2015 (https://www.euro.who. int/__data/assets/pdf_file/0018/281700/Self-assessment-tool-evaluation-essential-public- health-operations.pdf). 3. Resolucija o nacionalnem planu zdravstvenega varstva 2016 – 2025 “Skupaj za družbo zdravja” [Resolution on the National Health Care Plan 2016–2025 “Together for a Healthy Society”]. Ljubljana: Government Office for Legislation; 2016 (in Slovenian) (http://pisrs.si/Pis.web/ pregledPredpisa?id=RESO102). 4. European Programme of Work 2020–2025: United Action for Better Health. Copenhagen: WHO Regional Office for Europe; 2021 (page 12; https://www.euro.who.int/__data/assets/pdf_ file/0010/172729/Review-of-public-health-capacities-and-services-in-the-European-Region). 5. Health 2020: a European policy framework supporting action across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe; 2013 (https://www.euro. who.int/en/publications/abstracts/health-2020-a-european-policy-framework-supporting- action-across-government-and-society-for-health-and-well-being). 6. Register raka Republike Slovenije in drugi registri [Cancer Registry of the Republic of Slovenia and other registries] [website]. Ljubljana: Institute of Oncology; 2019 (in Slovenian) (https:// www.onko-i.si/rrs). 7. OPSI [website]. National Open Data Portal of Slovenia. Ljubljana; Ministry of Public Administration; 2021 (in Slovenian) (https://podatki.gov.si/). 8. Zakon o zbirkah podatkov s področja zdravstvenega varstva (ZZPPZ) [Healthcare Databases Act]. Ljubljana: Government Office for Legislation; 2020 (in Slovenian) (http://pisrs.si/Pis.web/ pregledPredpisa?id=ZAKO1419). 9. Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No. 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing. Official Journal of the European Union. 2015;359:6 (http://data. europa.eu/eli/reg/2015/359/oj). 10. OECD, Eurostat, WHO. A System of Health Accounts 2011: Revised edition. Paris: OECD Publishing; 2017 (http://dx.doi.org/10.1787/9789264270985-en). 11. International Health Regulations (2005). Third edition. Geneva: World Health Organization; 2016 (https://www.who.int/publications/i/item/9789241580496). 12. Resolucija o nacionalnem programu varnosti in zdravja pri delu 2018–2027 [Resolution on the National Programme of Health and Safety at Work 2018–2027]. Ljubljana: Ministry of Labour, Family, Social Affairs and Equal Opportunities; 2018 (in Slovenian) (http://www.pisrs.si/Pis.web/ pregledPredpisa?id=STRA75). 1 All URLs accessed on 7 July 2021. 65 13. Resolucija o nacionalnem programu duševnega zdravja 2018−2028 [Resolution on the National Mental Health Programme 2018–2028]. Ljubljana: Ministry of Health; 2018 (in Slovenian) (http:// www.pisrs.si/Pis.web/pregledPredpisa?id=RESO120). 14. Strategija razvoja Slovenije 2030 [Slovenian development strategy 2030]. Ljubljana: Government Office for Development and European Cohesion Policy; 2017 (https://www.gov.si/assets/vladne- sluzbe/SVRK/Strategija-razvoja-Slovenije-2030/Slovenian-Development-Strategy-2030.pdf). 15. Z znanjem do boljšega zdravja [For better health]. In: National Institute of Public Health [website]. Ljubjana: National Institute of Public Health; 2021 (https://www.nijz.si/sl/revijajavnozdravje). 16. Nacionalna strategija odprtega dostopa do znanstvenih objav in raziskovalnih podatkov v Sloveniji 2015−2020 [National Strategy for Open Access to Scientific Publications and Research Data in Slovenia 2015–2020]. Ljubljana: Ministry of Education, Science and Sport; 2015 (https:// www.gov.si/assets/ministrstva/MIZS/Dokumenti/ZNANOST/Strategije/National-strategy-of- open-access-to-scientific-publications-and-research-data-in-Slovenia-2015-2020.pdf). 17. Zakon o prostorskem načrtovanju (ZPNačrt) [Spatial Planning Act]. Ljubljana: Government Office for Legislation; 2017 (in Slovenian) (http://www.pisrs.si/Pis.web/pregledPredpisa?id=ZAKO4675). 18. International Classification of Functioning, Disability and Health (ICF) [webpage]. Geneva: World Health Organization; 2021 (www.who.int/classifications/icf/en). 19. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015 (https://sdgs.un.org/2030agenda). 20. Stronger collaboration, better health. Global Action Plan for Healthy Lives and Well-being for All. In: World Health Organization [website]. Geneva: World Health Organization; 2019 (https:// www.who.int/initiatives/sdg3-global-action-plan). 66 SubJECT INDEx A Access Accountability Addiction Adolescent Adult Advocacy Alcohol Analysis, Analyses Awareness b Behavioural C Campaign Cancer Cancer registry Caregiver Challenge Chemical Child, Children Chronic Civil society Cohesion Committee Communicable disease Communication Communication technology Community Consumer Cross-border D Data Database Dentist Detection Determinant Development Digital Dissemination Drug i, xv, xviii, xxi, 8, 17, 20, 33, 45, 46, 47, 48, 59, 61 xvii, xix, 22, 40, 41, 50, 54 17, 26, 43, 57 8, 18, 19, 45 9, 16, 19, 20 xii, xxi, 2, 19, 30, 45, 58, 59, 60 xviii, 16, 21, 23, 42, 44, 45 4, 7, 8, 9, 15, 22, 23, 29, 30, 36, 39, 48, 52, 54 xxi, 11, 12, 20, 41, 43, 57, 58 xviii, xix, 16, 21, 44 xviii, xxi, 16, 30, 41, 42, 43, 45, 57 20, 33, 46 xv, 7 21, 47, 48 xvi, xvii, xviii, 3, 10, 19, 31, 32 10, 11, 18, 57 8, 16, 17, 18, 19, 20, 44, 45 xvi, 8, 10, 25 xv, 59 xviii, 10 xvii, 1, 4, 11, 19, 60 xv, xx, 8, 10, 11, 26, 46 xv, xviii, xxi, 2, 11, 12, 13, 19, 25, 30, 37, 40, 42, 51, 53, 57, 60 30 xv, xvi, 1, 13, 15, 17, 18, 22, 23, 27, 32, 43, 45, 59, 61 xv, 12, 14, 41 8, 10, 14 xv, xvi, xviii, xix, xxi, 4, 7, 8, 9, 16, 17, 18, 23, 24, 25, 28, 30, 32, 33, 35, 36, 61 xvi, 7, 8, 13, 24, 25, 29, 35, 36 19, 25 xx, 2, 19, 20 xv, xviii, 1, 15, 16, 18, 19, 32, 43 xv, xvi, xviii, xx, 1, 10, 12, 17, 22, 23, 24, 26, 27, 28, 29, 31, 32, 33, 35, 36, 38, 39, 40, 43, 46, 49, 63 44 xix, 33, 35, 36, 59 11, 15, 17, 20 67 E Educate Education e-Health Electronic Enforcement Emergency Environment Environmental determinant Environmental health Equity Essential Evaluation Evidence Exercise Experience f Family Financing Food Food safety G Governance Government Guideline Gynaecology H Hazard Health data Health impact assessment (HIA) Health-information system Health promotion Health protection Health technology assessment (HTA) Health system Health-system performance Health threat Human resource xxi, 26, 57, 58 xv, xvi, 16, 17, 19, 20, 21, 26, 27, 29, 30, 38, 42, 45, 52, 60 xv, xvi, xviii, xxi, 26, 31, 57, 58 10, 17, 19, 31 xv, xviii, xix, 12, 16, 19, 25, 28, 29, 39, 45, 51 xvi, xvii, xviii, xix, 10, 11, 25, 37, 38, 51 xv, 10, 12, 18, 21, 22, 39 xviii, 16, 44 xvi, xvii, xviii, xix, 2, 12, 15, 28, 39, 42 15, 42, 45 xv, xviii, 1, 8, 22, 27, 35 xvii, 1, 22, 23, 28, 30, 33, 45, 50, 52, 57, 59 xvi, xviii, xx, 1, 4, 9, 13, 16, 17, 22, 23, 28, 30, 31, 32, 33, 44, 49, 53, 54, 60 xix, 11, 30, 38 7, 8, 9, 35, 36 xviii, 15, 19, 40, 45 xvii, 29 22, 41, 44 xv, xix, 2, 12, 13, 35 xv, xvi, xviii, xx, 2, 18, 20, 22, 25, 27, 28, 49, 51, 56 3, 15, 16, 22, 23, 25, 28, 29, 30, 32, 35, 37, 40, 42, 43, 49, 52, 56, 60 xix, 3, 10, 11, 16, 21, 30, 33, 37, 41, 47, 50 24 xix, 2, 10, 11, 37 xv, xix, 7, 9, 18, 35 xvii, 15, 22, 23, 39, 42 xv, xviii, 7, 12, 32, 54 xv, xix, 2, 15, 16, 17, 21, 26, 40, 42, 43, 44, 45, 54 xix, 2, 12, 28, 39, 40, 41, 43 xvii, xx, 23, 29, 49, 54, 59 xv, xviii, 1, 7, 9, 10, 11, 16, 22, 29, 31, 32, 35, 36, 39, 40, 45, 49, 51, 63 8, 9 xvi, 11 xvi, xx, 12, 20, 24, 25, 26, 27, 30, 40, 49, 51, 55 68 I Immunization Implementation Information system Indicator Indoor air Inequity Information technology Infrastructure Injury Innovation Inspection Insurance Integration Interdisciplinary International Intersectoral J Journal Journalist K Knowledge l Laboratory Leader Leadership Legislation Local Long-term care M Management Manager Maternal Medicine Media Mental Methodology Monitoring Municipality 8, 19, 46 xvi, xviii, xix, xx, xxi, 4, 7, 8, 9, 11, 13, 16, 17, 21, 22, 23, 28, 29, 30, 31, 35, 40, 47, 49, 50, 54, 58, 61, 63 xvi, 7, 12, 13, 18, 33, 35, 36 xv, xix, 13, 23, 29, 33, 35, 50 12, 39 xix, 2, 15 xvi 8, 10, 29, 31, 39, 52 15, 18, 42, 44, 57 xviii, 26 xviii, 25, 28, 39, 41, 51 7, 19, 20, 36, 46, 47, 54, 55 9, 18, 28, 30, 33 15 xv, xvii, xxi, 4, 7, 8, 9, 10, 11, 18, 22, 23, 26, 27, 29, 33, 41, 44, 46, 52, 57, 59, 60 xv, xvi, xvii, xix, 3, 8, 11, 12, 15, 16, 18, 22, 23, 29, 39, 41, 42, 54, 56 33 xx, 53 xx, 19, 23, 26, 33, 52, 60 xvii, xx, 10, 12, 25, 28, 29, 51, 55 xv, xvi, 4 22, 27, 28, 51 xviii, xix, xx, 13, 15, 16, 23, 28, 31, 35, 36, 39, 40, 41, 42, 44, 46, 48, 54 xv, xvii, 7, 11, 15, 17, 26, 30, 37, 42, 43, 57 xviii, xx, 9, 48 7, 20, 21, 22, 24, 25, 26, 27, 30, 31, 37, 48, 51, 58 xx, 17, 22, 52, 53 8, 19 xix, 8, 13, 19, 20, 21, 40, 60 xvi, xviii, 16, 30, 44, 53, 57, 58 xviii, 8, 17, 25, 42, 43, 44, 45, 51, 57 2 xix, xx, xxi, 2, 7, 9, 10, 13, 16, 17, 18, 22, 23, 26, 51, 59 43 69 N Noncommunicable Nongovernmental organization (NGO) Nutrition O Occupational health Online sale Opportunity Oral Organization Outdoor air P Paediatric Palliative Parliament Patient Patient safety Patient association Performance Physical activity Plan Policy Political Population Practice Preparedness Prevention Primary care Primary health care Priority Prison Private Process Programme Project Protect Public health capacity Public health programme Public health service Public health system 8 xvii, xix, 15, 16, 26, 27, 29, 40, 42, 43, 45, 50, 54, 57, 59 xv, 16, 17, 21, 22, 42, 43, 44, 57 xviii, xix, 2, 12, 15, 25, 39, 40, 51 xviii, xix, 14, 41 1, 27, 49, 63 20 xix, xx, 1, 10, 17, 26, 28, 29, 30, 33, 40, 48, 54, 56, 60 xv, 12 17 xviii, xx, 21, 25, 47, 51 xx, 22, 50 xix, 8, 9, 13, 19, 21, 28, 35, 36, 46, 47, 48, 58 xviii, xix, 12, 13, 39, 40, 58 xviii, xx, 48 23, 26, 29, 30 xv, 17, 21, 22, 42, 43, 57 xv, xvi, xvii, xix, xx, 1, 2, 10, 11, 15, 22, 23, 24, 26, 27, 28, 29, 30, 37, 38, 39, 40, 43, 45, 46, 49, 51, 54, 55, 59, 63 xvi, xvii, xxi, 1, 2, 7, 9, 15, 16, 22, 23, 24, 32, 33, 35, 42, 44, 49, 50, 52, 58, 59, 60, 61 xv, xvi, xvii, 7, 12, 23, 28, 31, 32 xv, xvii, xix, xx, xxi, 1, 2, 7, 8, 17, 19, 20, 22, 23, 25, 42, 43, 45, 46, 50, 54, 57, 63 xxi, 1, 2, 17, 21, 32, 33, 46, 48, 50, 52 xv, xvi, xvii, xviii, xix, 10, 11, 25, 37, 38, 51 xv, xvii, xviii, xx, 2, 15, 16, 17, 18, 19, 20, 21, 26, 29, 42, 44, 45, 46, 47, 54, 57 xv, xviii, 17, 19, 26, 45, 46 xx, 8, 9, 44, 46, 49, 52 xvi, xix, 1, 18, 29, 35, 42, 43, 45 xvii, xx, 19, 42, 46, 47 xviii, xix, 15, 16, 19, 20, 39, 42, 44 xv, xvi, xvii xix, xx, 1, 3, 4, 15, 17, 18, 22, 23, 25, 26, 32, 36, 39, 44, 46, 51, 54, 55, 57, 60, 63 xv, xvi, xvii, xviii, xix, xx, xxi, 9, 10, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 32, 33, 42, 43, 45, 46, 47, 51, 52, 54, 55, 59, 60 xv, xvii, xx, 8, 13, 21, 22, 24, 26, 28, 29, 31, 32, 33, 40, 41, 49, 55 xv, 12, 14, 18, 39, 46 xvi, xvii, xix, 1, 43, 49 xviii, xx, 26, 27, 30, 55 xv, xvi, xvii, xx, 1, 2, 3, 4, 19, 22, 23, 25, 26, 28, 29, 35, 49, 50, 51, 56, 63 xv, xvi, xviii, xx, 49, 63 70 Q Quality r Region Registry Regulation Rehabilitation Report Reproductive health Research Resource Response Risk Risk factor Risk assessment Road safety S Safety School Science Screening Security Self-assessment Sexual Skill Social Social determinant Social mobilization Spatial planning Sport Stakeholder Statistics Strategy Substance abuse Support Surveillance Survey Sustainable Sustainable development System xvii, xviii, xix, xx 1, 4, 7, 8, 9, 12, 13, 18, 20, 21, 25, 28, 30, 31, 35, 39, 40, 44, 48, 49, 50, 51, 58 xix, 1, 2, 3, 22, 26, 43, 52 xv, 7, 8, 35, 40 8, 9, 12, 13, 14, 16, 23, 39, 40, 44, 54 xx, 18, 21, 25, 42, 46, 47, 51 xv, xvii, xx, 9, 15, 23, 35, 50 xviii, 17, 45 xv, xvii, xviii, xxi, 2, 13, 17, 25, 30, 32, 33, 45, 51, 52, 59, 60, 61 xvi, xvii, xviii, xx, 1, 10, 11, 12, 17, 18, 20, 21, 24, 25, 26, 27, 29, 30, 31, 36, 37, 40, 49, 51, 52, 54, 55, 60 xv, xvii, xviii, xix, 2, 8, 10, 11, 16, 18, 25, 37, 38, 51 10, 11, 14, 20, 30, 37, 41, 46 8, 16, 20, 45, 60 xv, 10, 12, 13, 14, 25, 35, 51 xv, 8, 12, 13, 22 xv, xviii, xix, 12, 13, 14, 15, 18, 22, 25, 31, 39, 40, 41, 42, 51, 57, 58, 59 xvi, xviii, xx, 13, 16, 17, 18, 20, 21, 26, 42, 44, 52 45, 60 17, 19, 20, 23, 46 10, 16, 37 xv, xvi, xix, 1, 3, 4, 7, 16, 23, 25, 39, 49, 51, 54, 63 xviii, 17, 44, 45 xx, 52 xx, 1, 15, 21, 29, 40, 43, 45, 47, 58 xviii, xix, 2, 8, 15, 16, 18, 44 xxi, 2, 30 xvii, xviii, xix, 39, 41, 42 13, 17, 45, 60 xvi, 3, 12, 13, 14, 15, 22, 23, 33, 36, 37, 39, 40, 41, 43, 44, 45, 46, 57, 59, 61 7, 8, 13, 35 xvi, xviii, xx, xxi, 13, 16, 21, 22, 23, 29, 30, 33, 35, 37, 38, 46, 49, 51, 57, 61, 63 17, 25, 43, 51 xx, 1, 4, 9, 11, 13, 15, 21, 23, 29, 30, 31, 32, 33, 37, 40, 42, 44, 47, 51, 61, 63 xix, 2, 7, 8, 10, 16, 26, 45 7, 8, 29, 35 xx, 1, 2, 7, 12, 18, 28 1, 63 xv, xvi, xvii, xviii, xix, xxi, 7, 8, 10, 11, 13, 14, 16, 17, 18, 19, 21, 23, 25, 28, 31, 32, 35, 36, 37, 40, 44, 46, 49, 51, 54, 55, 58, 59, 63  71 T Technology Tobacco Toxicology Trade Training Transport Traffic u University v Vaccine Vaccination (anti-vaccination) Violence Vulnerable W Water Well-being Workforce 39, 49 xv, xviii, 16, 23, 42, 44, 45, 57 25, 51 14 xvi, xix, xx, 10, 11, 13, 18, 19, 21, 22, 26, 27, 30, 32, 38, 45, 52, 53 11, 13 13, 15, 18 4, 50, 51, 59 11, 19 xviii, 19, 46, 47, 57 xviii, 17, 18, 42, 45, 57 xv, xviii, 10, 17, 18, 19, 20, 42, 43, 45, 46, 57 xv, 12, 22 xix, 1, 2, 7, 22, 32, 63 xv, xvi, xviii, xx, 1, 2, 4, 8, 10, 11, 23, 24, 25, 26, 32, 38, 51, 52, 63 The WHO regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int